A Brief History of Coronavirus in Iceland
The Icelandic response to the COVID-19 epidemic has gained positive international attention. The country has been praised for the effectiveness of its test and trace approach which has allowed Iceland to contain the epidemic with less death and less disruption to everyday life than most other countries in Western Europe. This is all true. However, this article provides additional context by pointing out some miscalculations in the Icelandic response. Although the article focuses on these errors, you can, if you wish, take a hopeful message from it. Success in containing the virus is possible even with flaws in the response. The virus is not invincible and suppressing it does not require Taiwanese levels of competence and foresight.
The virus is “about as fatal as the flu”
Like many experts in the West, Icelandic experts estimated the lethality of COVID-19 as very low. In an interview on February 1, infectious disease specialist Bryndís Sigurðardóttir estimated that the real number of infected people in China was most probably much larger than the recorded number of cases, meaning that the real fatality rate was much lower, probably lower than that of influenza.
The head epidemiologist, Þórólfur Guðnason, estimated that the virus was about as dangerous as the flu. On February 26 he estimated that if the epidemic were to spread completely uncontrolled through Iceland with no action taken by the government the worst case would be 25 ICU cases and 10 deaths, comparable to the flu epidemic of 2009.
These numbers were based on the idea that the epidemic in Hubei was uncontrolled and stopped naturally with the population attaining herd immunity — the deaths per capita in Hubei were then applied to the Icelandic population. While critics suggested that an uncontrolled epidemic in Iceland would entail thousands of deaths the chief epidemiologist was still sticking by his model on March 15 though at that point he had slightly raised his estimate to 30 ICU cases. As events unfolded, Iceland reached 30 ICU cases on April 20 in what is certainly not an uncontrolled epidemic.
“We will attain herd immunity”
Since the virus was seen as highly contagious and low in fatality, the decision was made not to attempt to suppress it. Instead, the plan was for mitigation measures to slow down the virus while vulnerable people would be sheltered. Meanwhile, a large portion of the young and healthy population would get the virus and herd immunity would be reached.
The herd immunity plan was most clearly explained on March 15 by the chief epidemiologist in a press conference laying out the strategy:
“We know that a very large portion of the nation will get this infection. We want it to be only the healthy people who get the infection. We want to keep it away from vulnerable groups because we know that the overwhelming majority of healthy people who get the infection get a mild case. In this way we will get herd immunity, the community immunity which will allow us to protect the vulnerable.
If we were to introduce very tough measures, just closing everything down, then we would expect to get the epidemic later, when we open up again. … So we want to get some infection in the community, we want to get it slowly and we want the right people to get infected, not the vulnerable people.”
In a TV interview on the same day he explained further:
“We must get some infection in the community because this works like vaccination. So we can calculate that we must get maybe ca. 60% of the nation infected to create immunity to get the so-called the herd immunity so that the virus cannot continue.”
In a press conference on March 25 he still stuck by his view that “we will get herd immunity,” further explaining that suppressing the virus was an inferior strategy:
“It is entirely clear that infection in the community will create herd immunity and we have always said that we cannot prevent infection. It might be possible with some very hard measures but that would cost a lot and it would mean that we would get the epidemic again.”
The importance of not acting “too early”
Because the Icelandic plan was for the infection to spread at a moderate pace throughout the healthy population it was seen as important not to introduce a ban on mass gatherings “too early” as this would run the risk of slowing the infection too much and missing out on herd immunity. On March 4 Iceland had identified 29 infections but the message from the authorities was this: “We are not advising anyone to cancel anything”.
As many European countries introduced measures to reduce the spread of the virus, the Icelandic authorities faced pressure to do the same. Plans to ban mass gatherings were drawn up but put on hold until what was seen as the appropriate time. On March 12, Víðir Reynisson, head of the police response to the epidemic, explained that “if we do it too early and totally stop the epidemic” then the virus would simply come back in full force once the ban was released later on.
Countries which introduced tough measures early on were derided. Alma Möller, director of health, commented:
“In many countries there is no scientific basis for the actions taken, just politicians showing off. One thinks of Bulgaria for example, with 4 cases and a lockdown. This is just some political agenda, there is no science behind this.”
Þórólfur Guðnason similarly described measures enacted in Denmark and Norway as “colored by politics” and taken against the advice of experts.
The Icelandic ban on mass gatherings took effect on March 16 and was tightened considerably on March 24. But even after this, the measures were much lighter than in many European countries. Universities and secondary schools shifted to remote teaching but school for children went on with some restrictions. Theaters, swimming pools and gyms were shut but there was no general lockdown or closing of shops. These measures were intended to slow the spread of the virus but they were not intended to stop it.
Testing and tracing is only “phase one”
The Icelandic plan included broad testing for the virus, isolation of the infected and quarantining of their contacts. This has been key to the Icelandic success. But, interestingly, this was not originally intended to be the main battle plan against the virus. These measures were meant to slow the spread early on but the experts did not expect them to actually contain the outbreak. Once the infection was widespread the plan was to move on to phase two — mitigation. At that point, testing would be reduced, quarantine would be dropped and the focus would turn to strengthening the healthcare system to service the severely ill.
One part of the Icelandic success story was the offer by deCODE genetics to do open screening for the virus. As this was being planned, Dr. Kári Stefánsson explained that he expected deCODE to find that the virus was already widespread in the country. He noted that if this was the result quarantine measures would be pointless and should be dropped since they were a burden on society.
As things turned out, the deCODE screening revealed that the infection was not widespread in Iceland. This was part of the story of how the Icelandic authorities came to realize that the containment measures, expected only to slow the spread, might actually be effective enough to stop it. At the same time, the experts were coming around to the view that the disease was far more deadly than influenza and might need to be suppressed rather than merely slowed down. The result was that Iceland stayed in the containment phase and never moved on to the planned mitigation phase.
It is difficult to tell precisely when the Icelandic authorities switched goals from mitigation to suppression. No official announcement of a change in policy has ever been made. But an interesting reference point is an interview with prime minister Katrín Jakobsdóttir on April 16 where she states that “the goal should be zero infections.”
An island story?
Articles on the success of Iceland often point out that the country is an island, like Taiwan, and well-positioned to control its borders. This advantage, however, has played little part in the Icelandic response. While Icelandic travelers from high-risk areas were ordered into quarantine upon their return, no restrictions were placed on foreign visitors to Iceland. The risk of infection from tourists was estimated as relatively small and since the plan entailed herd immunity anyway, some occasional infection from travelers was seen as acceptable. Thus, Iceland did no health screening at its airports, did not restrict travelers from East-Asia while that was the epicenter of the outbreak and did not restrict travelers from Europe once the outbreak had moved there. Iceland protested the US travel ban on March 14, protested the closing of the Schengen border a few days later and continued admitting travelers from Europe, even from heavily infected countries.
However, as the chief epidemiologist realized that the Icelandic measures seemed to be suppressing the outbreak without creating herd immunity he decided that the only way to prevent a second wave was to stop the virus at the border, recommending as much to the government. Thus, Iceland finally instituted border controls on April 24 with a requirement of two weeks in quarantine for everyone entering Iceland. This was a painful step for a country dependent on tourism, taken with the greatest reluctance after the authorities had reviewed all other possibilities. In 2019, Iceland had more than 2 million foreign visitors against a native population of 364 thousand. Even in 2020, a report on April 14 noted that “since the beginning of the year, 334 thousand foreign passengers have departed from Iceland”.
The Icelandic case is emphatically not the story of an isolated island that quickly shut down its borders. The success came from testing, tracing, quarantine and social distancing with relatively modest shutdown measures. Of course, only time will tell whether the first wave will be reduced all the way to zero and how successful the border controls will be at preventing a second wave.