Policy responses for Sweden - HSRM


Policy responses for Sweden

1.5 Testing

Since June 2020, the testing strategy includes mass testing of all individuals experiencing COVID-19 symptoms. In November 2020, around 250,000 tests were performed per week and nearly all regions report on having nearly reached their maximum capacity for testing.

Since February 2021, the testing capacity has steadily improved, and the number of PCR-tests has been between 200,000 and 250,000 and increasing, with around 20,000 antibody tests and 30,000 antigen tests having been performed per week.

On March 2nd 2021, infection tracing was intensified in workplaces such that once a COVID-19 case is discovered, all individuals with close contact will be tested, both symptomatic and asymptomatic.

Weekly statistics of PCR and antibody tests performed is published on the following site (in Swedish): https://www.folkhalsomyndigheten.se/smittskydd-beredskap/utbrott/aktuella-utbrott/covid-19/statistik-och-analyser/antalet-testade-for-covid-19/

A number of commercial antigen tests are available on the market, many of which have not undergone comprehensive independent evaluations. These products must meet certain standards and may be prohibited for sale by the Medical Products Agency unless they fulfil these. Rapid tests should be performed by trained professionals and are not suitable for self-testing by laymen/consumers.

Rapid tests/antigen test subsidized by the government must be performed by health care professionals or other competent staff in order to receive compensation. This is according to the agreement (signed on December 17th 2020) between the government and the Swedish Association of Local Authorities and Regions. The regions may task private actors such as occupational health care actors to perform testing on behalf of the region given that they fulfil these terms.

Antigen tests are recommended to be used in sensitive care environments close to patients. In this environment it is of great value to break the chain of infection early to protect both patients and caregivers and maintain ordinary activities.

All positive test results shall by law (the Communicable Diseases Act) be reported to the national system SmiNet by laboratories and doctors.

On February 9th 2021, the Public Health Agency was tasked with increasing sequencing capacities to monitor and map out variants of SARS-CoV-2 that might cause a vaccine breakthrough. The goal is to build up capacity during 2021 where at least 10% of all positive test samples are whole genome sequenced. The technology is already used in nearly all university hospitals in Sweden but has to be adjusted to COVID-19 sequencing. The agency shall, in accordance with the risk assessment of European Centre for Disease Prevention and Control (ECDC), track the prevalence of three variants in particular (the British variant, the South African variant and the Brazilian variant), these have been named ‘variants of concern’ (VOC).

Statistics of variants of concern is published on the follow site (in Swedish): https://www.folkhalsomyndigheten.se/smittskydd-beredskap/utbrott/aktuella-utbrott/covid-19/statistik-och-analyser/sars-cov-2-virusvarianter-av-sarskild-betydelse/


To confirm ongoing COVID-19, PCR-tests are performed. The Public Health Agency has established a priority order for sampling.
• Priority group 1: Patients, persons with risk factors and persons in long-term care
• Priority group 2: Personnel in the health care and social care systems
• Priority group 3: Personnel in other critical societal sector
• Priority group 4: Other relevant parts of the society
The state budget covers the cost for samples and analysis for all patients with symptoms, after a medical assessment. On June 4th the government and the Public Health Agency announced that the priority groups no longer apply. Instead, symptoms and the need for contact tracing will guide testing. Since the outbreak, the agencies and counties have been working constantly to increase the capacity to test and on March 30th, the Public Health Agency was mandated by the Government to further develop a strategy to increase the test capacity.

The goal is to have a capacity of 21,500 PCR-tests per day (~ 200 samples per day per 100 000 people)  According to the latest version of the national strategy for testing, the national capacity is about 20,000 samples per day. Samples are analysed in clinical microbiological laboratories in 19 of the 21 Swedish regions. The two counties that do not perform COVID-19 diagnostics, have well-established transport routes to nearby laboratories. The performed PCR-testing has increased from about 600 samples per day at the beginning of March to about 7,566 samples per day at the beginning of August (from 6 to 73 samples per day per 100,000 people). The number of performed tests reached a maximum level in the middle of July, when 11,500 samples were performed per day (113 samples per day per 100,000 people).
On June 4th the government announced that the state budget will cover the counties’ costs for serological testing for antibodies. The ambition is to offer free serological tests for personnel in health care and long-term care for older people as well as personnel in other critical societal sectors. The government aims to offer the rest of the population serological tests for patient fees. The testing for antibodies also peaked during July, when 9,650 samples were performed per day (93 samples per day per 100 000 people). At the beginning of August, 7,805 samples for antibodies were performed per day, corresponding to 76 samples per day per 100,000 people.

Timeline for testing
• Initially the aim of the testing strategy was to stop domestic infections. Travelers from high-risk regions abroad who developed respiratory symptoms such as cough, difficulty breathing or fever were followed up with sampling and contact tracing.
• February 13th. In addition to the Public Health Agency’s laboratory, a total of eight clinical microbiological laboratories will be able to test for COVID-19.
• On March 4th. The Public Health Agency recommends that all clinical microbiological laboratories performing tests for COVID-19 to search for the virus in samples from patients with respiratory symptoms without a known cause, which have already been negative for other diseases.
• On March 13th. In order to best prioritise resources, the testing strategy shifted to protect the most vulnerable and those most exposed to the virus. The following groups were prioritized for testing: (i) hospitalised patients and (ii) people that work in health care or care for older people, with suspected COVID-19.
• March 30th. The Government tasked the Public Health Agency with developing a strategy to increase the test capacity while retaining quality.
• April 1st. New test material for COVID-19 was delivered to a laboratory at the Karolinska Institutet and SciLifeLab’s Centre for Translational Microbiome Research (CTMR). The delivery included analysis reagents for detecting the virus’s RNA and five new laboratory robots. The new testing equipment will expand the testing capacity by about 5,000 analyses per day over the coming weeks.
• April 17th. The Public Health Agency presents the first version of a national strategy to increase testing capacity. The goal is a nationally secured, durable and robust testing capacity, primarily for patients and people in the health care and social care systems. Secondly for health care and social care personnel and thirdly for people in other essential sectors, for example the police force. The agency estimates that to fulfil the goal, the analysis capacity for COVID-19 needs to be increased to a total of 150 000 samples per week.
• April 21th. The Swedish Medical Products Agency's strongly discourages persons and companies from buying and using tests for home use to detect COVID-19.
• April 30th. The Public Health Agency presented an updated national strategy to increase testing capacity. The strategy includes two parts. The first part covers testing for ongoing infections, through PCR-tests. The second part of the strategy covers testing for antibodies, i.e. test to see if you have had the disease or not, through serological methods.
• May 8th. A national test coordinator has been established at the Public Health Agency with the task of coordinating the regions for large-scale testing of ongoing COVID-19 infection.
• May 19th. The Public Health Agency updated the prioritising groups. In the first prioritising group, all patients seeking health care are included. Previously, only patient who sought care in hospital were included.
• May 19th. The government announced that the state budget will cover the cost for test sampling and analysis of people in priority groups 1–3. Previously, the government covered the cost for priority groups 1 and 2.
• May 27th. Through a private donation, 15,000 health care workers were offered serological testing for antibodies in Stockholm and Gothenburg.
• May 29th. The Public Health Authority published a support document for how sampling can be organized in long-term care for older people. The document is addressed to management and medically responsible nurses and doctors working in long-term care for older people.
• May 29th. There is an ongoing debate about why the testing capacity does not increase at a higher rate. There are different opinions about whether the regions are responsible for the coordination of the sampling of priority group 3 or not. The laboratory capacity exceeds 100,000 samples a week, but still only about 30,000 test per week are performed.
• May 31st. The national test coordinator ends her mission.
• June 4th. The government propose to allocate SEK 5.9 billion for increased testing and contact tracing. According to the government, several regions are now entering a new phase of the pandemic, where again there is a reason to conduct more extensive and active contact tracking in order to further reduce the spread of infection. Most of the investment will go to the counties. The Public Health Agency shall support regions, county councils, municipalities and other stakeholders by ensuring that all necessary testing structures and the consequences of testing are in place in the near future.
• June 4th. The Public Health Agency published guidance for serological testing. The document is addressed to organizations that intend to provide antibody test. According to the guidance, antibody tests have limited value, especially at the individual level, as long as the proportion of individuals who have had infection are low.
• June 8th. Several counties expand the sampling for ongoing COVID-19. All residents in these counties with symptoms can be tested in primary care through self-referral.
• June 15th. Stockholm region offers tests for antibodies and tests for ongoing disease to all citizens. Several other regions are doing the same.
• Oct 30th. The government allocates an additional SEK 3 billion to the regions in 2020 to meet the need for large-scale testing. Large-scale testing throughout the country provides good opportunities to detect potential carriers and contribute to effective infection tracing. In November 2020, 140,000 PCR tests and about 30,000 serological tests (antibody tests) have been performed per week.
• Dec 17th. the government signs a deal with the Swedish Association of Local Authorities and Regions (SKR) about rapid antigen tests. The Swedish state undertakes to co-finance regional testing from January 1st 2021.
• Jan 12th, the government allocates an additional SEK 5.5 billion for massive PCR-testing during 2021.
• Jan 27th, the government allocates SEK 1.4 billion for rapid antigen tests during 2021.