Danish Paradox: High COVID Transmission Leads to Endemicity

Our third look at Denmark since the Omicron variant was identified (see first and second posts) centers on the decision by the government to essentially declare COVID-19 an endemic disease, or as the Danes call it, no longer a "socially critical disease." First, we look at transmission.

On Feb. 12, Denmark had the world's highest rate of coronavirus infections: 790 cases per 100,000 people, averaging nearly 47,000 daily infections. The Netherlands was second with 710 cases per 100k people, according to The New York Times global tracker. By comparison, case incidence in the U.S. was 53 per 100k people.

Since our second post just over a month ago, cases have jumped over 160%. The Jan. 10 post indicated:

Daily new cases have increased to a 7-day average of over 18,000 on Jan. 8, an increase of almost 70% during the last 2 weeks, according to the Times tracker. While no longer on the tracker's 'top 10' list in case incidence, a sign that Omicron is becoming dominant globally, it is #14 with 311 per 100,000 people.

Decoupling cases and hospitalizations

Yet Danish health authorities have apparently determined that the number of people becoming infected daily with COVID is essentially irrelevant. They have done what U.S. health officials suggested in a post last month about increasing COVID hospitalizations during the Omicron wave:

Former FDA Commissioner Scott Gottilieb, MD, centered the role of hospitals in assessing the severity of the omicron variant. He told CBS Jan. 2 that "there's a very clear decoupling between cases and hospitalizations."

That "decoupling" has led to Denmark becoming the first European country to end most coronavirus restrictions on Feb. 1, as POLITICO reported on Jan. 26.

Denmark will no longer categorize COVID-19 as a "socially critical disease" as of February 1, Health Minister Magnus Heunicke wrote in a letter [pdf] to the parliament's epidemiology committee.

Based on the recommendations of the parliament's epidemiology committee, the government is ready to scrap almost all social restrictions by the end of the month. The "rules will lapse when the illness will no longer be categorized as ‘socially critical’ on 1 February 2022," Heunicke wrote in the letter.

On Feb. 1, the AP reported that the restrictions, indeed, were lifted.

“I dare not say that it is a final goodbye to restrictions,” Prime Minister Mette Frederiksen told Danish radio. “We do not know what will happen in the fall, whether there will be a new variant.”

But they are hardly alone. The piece notes the relaxation of restrictions in the U.K., Ireland, France, and Finland, and describes existing or tightening restrictions or vaccination requirements in Serbia, Italy, Austria, and Germany.

Socially critical disease

To get a better understanding of why the world's most infected country decided to toss almost all restrictions, Derek Thompson of The Atlantic interviewed Michael Bang Petersen, a Danish researcher and political science professor at Aarhus University who led a global survey of COVID attitudes and advises the Danish government.

Thompson writes (in the source article):

"If you are following Denmark’s infection numbers, this seems like a very, very strange thing to do,” Petersen told me.

On [Feb. 2], Petersen and I talked about Denmark’s decision, how the country maintains the trust of the public during confusing times, why it’s smart to announce an expiration date for COVID restrictions, and why so many in Denmark are strongly pro-vaccine but also strongly anti–vaccine mandate.

Central to the decision is what Gottlieb had told CBS (noted above in the first section) a month earlier. From the interview:

Michael Bang Petersen: The decoupling of cases and hospitalizations comes from two things. First, Denmark has very high vaccine uptake, with 81 percent of the population having two doses and 61 percent having received a booster shot. Second, Omicron is a milder variant. That combination of high vaccine coverage plus a milder variant means this wave isn’t stressing our hospital systems as much.

Asked why not wait until cases drop before lifting restrictions, Petersen explained the "socially critical disease" declaration.

Petersen: In order for the Danish government to keep restrictions in place, the disease has to be classified as a threat to the critical functions of society. That is a temporary classification. It only lasts for a few months at a time. The government must purposefully decide to extend the classification every time.

The latest extension was set to end in February. The government had a deadline. We had to decide: Can we really make the case that COVID is a threat, at this moment, to the critical functioning of society? This is a black-or-white decision for us—either COVID is critical or it’s not—and we couldn’t make the case that this poses a societal threat. That’s why we decided to lift all restrictions, including the mask mandate, effective February 1.

Thompson asks if public opinion is part of the government’s decision-making. A recent post about the U.S. having one of the world's highest per capita death rates notes that there is a high correlation between infection rates and a "country’s level of distrust" in its government.

Pro-vaccine + anti-vaccine mandate

The interview ends with Thompson noting that Søren Brostrøm, the director-general of Danish Health Authority had stated:

"I do not believe in imposed vaccine mandates. It’s a pharmaceutical intervention with possible side effects. I think if you push too much, you will have a reaction. Action generates reaction, especially with vaccines.”

Thompson observed that "[i]n the U.S., it’s less common to find people who are strongly pro-vaccine but also loudly anti–vaccine mandate." He asked, "How common is this view in Denmark?"

Petersen: In Denmark, people are in favor of vaccines, with more than 81 percent of adults doubly vaccinated, but also very opposed to vaccine mandates. There are no political parties in Parliament that are loudly advocating for vaccine mandates. 

But also, research suggests that vaccine mandates might enhance what makes people anti-vaccine in the first place, like distrust of authorities and feeling like they’re being forced to do something that’s bad for them.

However, Denmark was the first European country to use vaccine verification, the Coronapas passport, which also accepted a negative COVID test result, to help non-essential businesses reopen.

Boosters and Denmark

We end with a few excerpts from a Yahoo News article published on Feb. 3 on the importance of being boosted, and America's "booster deficit."

A new CDC study of the Omicron surge in Los Angeles found that while vaccinated people were 5.3 times less likely to end up in the hospital than the unvaccinated, boosted people were 23 times less likely to do so, meaning that boosters afforded four times more protection against hospitalization than a first-series vaccination alone.

The piece began by noting that Denmark had lifted most of its coronavirus restrictions on Feb. 1, "a moment that millions of Americans have been longing for, especially as the Omicron wave that began in December appears to be subsiding," wrote Andrew Romano and Alexander Nazaryan. They went on to make several comparisons between the U.S. and Denmark.

But whatever the causes of America’s booster deficit, the cost is now being measured in lives.

According to a Financial Times analysis published Monday [subscription may be required], 30 percent of U.S. seniors had gone six months since receiving a second dose as of Dec. 20 — when Omicron was taking off — compared with just 7 percent in Denmark. As a result of this weaker coverage among those most susceptible to serious disease — another 12 percent of U.S. seniors remain entirely unvaccinated — the FT calculated that the U.S. was twice as exposed to COVID hospitalization as Denmark during the Omicron wave.

The increased protection that comes from being fully vaccinated, 81 percent of Denmark's population with 61% boosted compared to 64% in the U.S. with 43% boosted, was one of the reasons that Denmark chose to declassify COVID-19 as a "socially critical disease," according to Professor Petersen.

Related posts – Denmark I and II:

• Coronavirus Geography: Denmark Could Be an Omicron Harbinger, December 27, 2021
• Pandemic Endgame: Danish Epidemiologist's Prediction, Jan. 10, 2022

Others:

• State Hospitalization Record Breaks as Omicron Surges, January 4, 2022
• The Great Scandinavian Pandemic Experiment, May 13, 2020