Sweden’s response to public health crises is governed by statute. Smittskyddslagen (the Communicable Diseases Act) regulates the response to outbreaks and threats of outbreaks of contagious diseases. Power and responsibility for the containment of contagious diseases are shared between state and local authorities. Both individual patients and treating physicians have a duty to report cases of possible contagious disease. Coercive powers such as isolation, quarantine, and restrictions on work and travel are available to the state but only as specified by law and only if there is a serious threat that a dangerous disease may spread. The intentional and negligent spreading of a disease is a crime. The National Board on Health and Welfare is responsible for coordinating with the World Health Organization. Sweden has not had to respond to a public health crisis recently.
I. Structure of Public Health Crisis Management System
A. General Government Structure
The national government, municipalities, and local county councils share power on issues of public health crisis management. Municipal self-governance is fundamental to the Swedish system and is explicitly listed as a right in the Swedish Constitution. The municipalities are generally responsible for health care, education, and elder care.
1. General Principles
Sweden does not have overarching legislation that deals with all public health crises but instead uses individual acts and regulations that deal with crises in different areas—for instance the Communicable Diseases Act deals with protection against infectious diseases. This report focuses solely on the infectious disease aspect of public health crises and thus only covers the Communicable Diseases Act and its relevant ordinances, procedures, etc.
While Sweden has no overarching legislation it has general guiding principles that apply to all crisis management efforts. These are the principles of responsibility, equal treatment, and “geographic closeness” (whereby authority is determined by proximity to the crisis). This means that Sweden also has a general division of responsibility between national and local authorities that is similar in all crisis management situations.
2. Smittskyddslagen (Communicable Diseases Act)
The main legislation covering contagious diseases is the Communicable Diseases Act. The Communicable Diseases Act classifies diseases into three different categories: (1) contagious diseases, (2) diseases dangerous to public health, and (3) diseases dangerous to society. Contagious diseases are diseases that can be transferred between individuals and that pose more than an insignificant threat to the health of the individual contracting it. Diseases dangerous to public health are contagious diseases that can be “life-threatening, result in continuous illness or difficult suffering or cause other serious consequences where there is a possibility of preventing the spread of the disease through measures aimed at the infected individual.” Diseases dangerous to society are diseases that are dangerous to public health and can spread in society in a manner that would create a serious disruption or imminent risk of a serious disruption of important public functions, and demand extraordinary measures. All diseases classified as dangerous to public health or dangerous to society, and some communicable diseases, are subject to mandatory contact tracing. These diseases are referred to as “diseases that must be reported” or “contact tracing diseases,” depending on whether the disease must be traced and reported or only traced.
The government decides how to classify each illness. Currently diseases dangerous to public health include: campylobacteriosis, diphtheria, bird-flu (H5N1), E.coli (EHEC) infection, giardia infection, gonorrhea, hepatitis A-E, HIV infection, infection with HTLV I or II, chlamydia, cholera, infection with methicillin-resistant staphylococcus aureus (MRSA), anthrax, paratyphoid fever, plague, infection with pneumococci with reduced susceptibility to penicillin G, polio, rabies, salmonella infection, shigellosis, smallpox, severe acute respiratory syndrome (SARS), syphilis, tuberculosis, typhoid fever, and viral hemorrhagic fevers except Dengue fever nefropathia epidemica. Diseases dangerous to society include smallpox and SARS, and, as of October 23 2014, Ebola. Ebola was added to the list by the Swedish government following a request from the National Board of Health and Welfare (NBHW). These classifications determine the lawful measures that the national, municipal, and local representatives may take to intervene to stop the spread of the disease and provide treatment.
3. International Measures
Sweden has implemented the World Health Organization’s (WHO’s) 2005 International Health Regulations into law. The implementing legislation divides responsibility between the municipalities, which are responsible for animal protection, the county councils, which are responsible for human protection, and the NBHW, which is responsible for coordination. All diseases dangerous to society that are listed in the Communicable Diseases Act are also considered international threats to people’s health. Currently this list includes smallpox, SARS, and Ebola. The government decides what additional diseases are considered a serious threat to society. All serious diseases are subject to the Communicable Diseases Act.
International public health threats are monitored by the NBHW, and all national and local authorities must report any discovered threat to that Board. The NBHW must in turn inform WHO within twenty-four hours of receiving such reports. In addition, the NBHW must cooperate with international organizations and foreign governments to combat international health threats. Information provided to the WHO should be submitted even if it is covered by domestic secrecy laws.
Compliance with the aforementioned legislation is monitored by the Health and Social Care Inspectorate. Decisions made relying on the authority of the Act can be appealed to the administrative courts.
4. Preparedness for Extraordinary Events in Times of Peace
Other legislation related to public health crisis management includes a specific act on how municipalities and county councils should prepare for extraordinary events during peace time, as well as a regulation on emergency preparation and heightened preparedness. Regarding extraordinary events, each municipality has a responsibility to implement a Crisis Management Committee. According to the regulation on Emergency Preparation and Heightened Preparedness, county administrative boards have the overall responsibility for their region’s preparedness, but all agencies have joint responsibility to cooperate with each other. Each authority is required to continuously monitor the threat level and make adjustments to their preparedness levels accordingly. The analysis of the threat and weakness level should culminate in a “risk and weakness report” that is sent to the government and the Swedish Civil Contingencies Agency.
C. Responsible National and Local Authorities
1. Responsible National Authorities
On the national level, public health crisis management is divided between a responsible authority that coordinates with national entities, an expert authority that tracks public health threats and builds a planned response, and local authorities that monitor and react to public health threats.
The main national actors in public health crisis management are the Ministry of Health and Social Affairs, the National Health and Welfare Agency, the Swedish Civil Contingencies Agency and the NBHW. The responsible government department for public health crisis management is the Ministry of Health and Social Affairs.
The expert authority on public health crises (infectious diseases) is the National Health and Welfare Agency. It is responsible for monitoring global and national developments in communicable diseases, informing the government and local health care providers of the current state of threats, and proposing actions on how to combat these threats. The Public Health Agency of Sweden is also responsible for all laboratory testing related to the Communicable Diseases Act.
The Swedish Civil Contingencies Agency is responsible for supporting designated agencies with measures and information, and for providing information to the public. Its primary focus is to coordinate efforts and to train personnel in preparedness for national contingencies, as well as to develop better routines for this work. The Agency is also responsible for medical research on how to prevent communicable diseases from spreading.
The NBHW acts with authority from the Ministry of Health and Social Affairs and is the national coordinating authority on communicable diseases, whereas the National Health and Welfare Agency is the expert authority. The NBHW or the government may also issue instructions on responding to public health crises. In September of 2014 the NBHW issued new (nonbinding) guidelines for how suspected Ebola cases should be treated. In addition the NBHW is responsible for reporting pandemic cases to the WHO (IHR).
On the national level, a special working group, the National Pandemic Group, has been created to focus on pandemic threats. The Group consists of the directors for the NBHW, the National Health and Welfare Agency, the Swedish Work Environment Authority, the Medical Products Agency, and the Swedish Association of Local Authorities and Regions. It meets at the discretion of the NBHW.2. Responsible Local Authorities: County Councils and County Medical Officers
On the local level, public health crises are managed by the local health authorities known as the county councils, which are responsible to the municipality and county administrative board. Each county council is overseen by a county medical officer (CMO) and is responsible for health services in general within its region. Local health care providers and the CMO are the points of first contact for most public health crises. Although County Councils are normally only responsible for the residents of their own municipality, all County Councils should cooperate among themselves during extraordinary events. All county councils must provide for the necessary precautions against transmission of disease.. The county councils must also maintain a contingency plan. The local power to take forcible measures against individuals to combat a public health crisis is vested in the CMO.
The CMO has primary responsibility for the prevention and containment of communicable diseases. He or she must “plan, organize and lead the effort and work for efficiency, coordination and consistency.” This includes ensuring that local residents have access to information on communicable diseases and the response thereto, providing guidelines and support, ensuring that preventative steps are taken to prevent diseases from spreading, supporting treating physicians, following up on reported illnesses, ensuring that persons who carry a communicable disease get the support and care needed, ensuring that measures are taken to prevent the spread of disease, and continuously following the local status of communicable diseases in the region. CMOs are also required to cooperate with CMOs from other regions and may transfer cases between themselves.
D. Specialized Hospitals
In addition to national and local authorities that follow and monitor potential contagious threats, Sweden also prescribes by law that specialized expertise should be vested in individual public hospitals designated to accept and treat patients from anywhere in Sweden. These specialized hospitals are responsible for national expertise in a specific area and are overseen by the NBHW, which grants a hospital the privilege of being a national hospital and issues the conditions that it needs to follow to maintain that status. The Board’s decisions cannot be appealed.
Linkoping University Hospital (a public hospital) is the specialized hospital on infectious diseases with capabilities to care for infectious patients in isolation for a prolonged period of time. The unit is specifically tailored for high-risk diseases such as Ebola and includes three separate “treatment rooms.” It also has access to a specialized ambulance as well as airplane transportation. Patients suffering from infectious diseases are transferred to Linkoping from other Swedish hospitals and it must be prepared to transport infected Swedes from anywhere in the world.
E. Nordic Cooperation
1. Nordic Public Health Preparedness Agreement
Sweden cooperates with other Nordic countries on health care. The Nordic Public Health Preparedness Agreement between the Nordic countries signed in Svolvær on June 14, 2002, makes treatment in another Nordic country possible in cases of national crises when Swedish resources are strained. Likewise, Sweden has an obligation to help its neighbors in their time of need. Specifically, the Nordic countries have agreed to “provide assistance to one another upon request”; “promptly inform of measures planned or implemented that impact the cooperation”; “promote cooperation and insofar as possible remove obstacles in national legislation, regulations, and other rules of law”; “provide opportunities for the exchange of experience, cooperation, and competence-building”; “promote the development of cooperation in this area”; and “inform one another of relevant changes in the countries’ preparedness regulations, including amendments to legislation.” The Nordic Public Health Preparedness Agreement supplements the 1989 Nordic Rescue Service Agreement. Currently, no patients are being treated under the Agreement.
2. General Nordic Cooperation
The Nordic countries also cooperate generally in health care. During a meeting in Reykjavik in 2014, fourteen suggestions for deeper cooperation on health care issues were presented. Sweden has general Nordic cooperation with its neighbors through Nordred, a cooperative civil protection agency among the Nordic countries. Only one infectious patient was treated in another Nordic country during the 2005–2007 period.
3. Baltic Sea Cooperation
A special action group against contagious diseases was set up at the Council of the Baltic Sea States (CBSS) meeting in Kolding, Denmark in 2000. Epidemic surveillance, HIV/Aids, tuberculosis, and antibacterial resistance, as well as primary care, were recognized as the most central issues to the region.
II. Powers of Public Health Authorities
As mentioned above, national and local authorities share responsibilities and powers to act in the face of a public health crisis. The NBHW has the power to seal off and quarantine certain areas and require that individual travelers arriving from certain areas be quarantined. The CMO is responsible for the local response to a public health crisis. As such, the CMO investigates the need for mandatory testing of suspected ill individuals; petitions the courts for mandatory testing of suspected ill individuals; issues, amends, and reviews care instructions for proven ill individuals; and petitions courts for the isolation of infected individuals. In urgent situations, the CMO has the power to place a person in temporary isolation provided that the CMO notifies the court within four days to review the continued isolation. Whereas the NBHW is responsible for designating quarantine areas, the County Medical Officer is responsible for the quarantine of people who are thought to be carriers of an illness and may demand testing of people arriving from abroad. The CMO can also demand information on a patient from other government and local agents who have come in contact with the patient.
B. National Mandatory Notification Systems
The Communicable Diseases Act requires that certain infectious diseases be reported. Reportable diseases include, for example, chlamydia, HIV, and during the 2009 pandemic the A(H1N1) (swine flu) influenza.
1. Responsibilities of Medical Personnel
A treating physician who comes into contact with an infected individual is required to report the disease to the local CMO as well as to the Public Health Agency of Sweden without delay. The provision also applies to pathologists and laboratory physicians. The notification should include:
1. the infected or suspected infected patient’s name, Swedish social security number, or government coordination number as well as address;
2. the likely source of the infection;
3. the likely spread of the disease;
4. any and all measures that the physician has taken to prevent the spread of the disease; and
5. other information that will affect the spread of the disease.
“Other information” includes whether or not the individual was a blood donor.
2. Mandatory Self-reporting and Information
A potentially sick person has the obligation to seek medical care to find out whether or not he or she is a carrier for a contagious disease covered by Communicable Diseases Act. The requirement does not include an obligation to undergo treatment for the disease. The patient must, however, inform the doctor of potential sources of the disease and indicate whether other individuals may have been infected.
Captains of ships and airplanes are required to inform Swedish Customs about any potential disease on board and Swedish Customs in turn is required to inform the County Medical Officer.
C. Powers of Disease Control
Once an illness has been diagnosed the local CMO has the power to put in place certain sanctions. These sanctions may not go beyond what is required to contain the disease. The treating physician must, in conjunction with the patient, work out a treatment plan for the treatment and containment of the disease. If this plan is violated the CMO may intervene.
1. Issuing Individual Formal Instructions to Patients
After a patient has been diagnosed with a contagious disease the treating physician should create individualized, formal instructions for the patient to follow to minimize the risk of spreading the disease. The instructions may only include the following measures:
1. limits on socialization that pertain to work, education, or participation in other activity,
2. prohibition on donating blood or organs,
3. prohibition on lending or otherwise transferring used injection devices,
4. duty to inform caretakers and others, who perform nonmedical procedures on the patient, of the disease,
5. duty to inform sexual partners that he/she is carrying the disease,
6. duty, during sexual contacts, to adopt a behavior that minimizes the risk of spreading the disease,
7. duty to practice special hygienic routines, and
8. duty to keep in regular contact with the treating physician.
These instructions shall be communicated in writing as soon as possible as well as be included in the patient’s health record. The treating physician shall as far as possible make sure that these instructions are followed.
If the formal instructions are not followed the patient may be placed in isolation, if the risk to others requires isolation.
2. Patient Isolation
Patients carrying a contagious disease may be placed in isolation for up to three months, which may be extended by six months at a time. During the isolation period the patient has the right to one hour of outside time per day as well as telephone calls. The patient also has the right to visitors, if visits can be conducted safely. Isolation can only be ordered if there is a violation or risk of violation of the formal instructions or if it is otherwise the only way to contain the disease. There must be a “considerable risk that others may be infected.” The European Court of Human Rights has ordered Sweden to pay damages to an HIV patient who was isolated for years, stating that there was not sufficient cause to keep him isolated.
3. Extraordinary Measures
Testing of individuals for a disease at ports of entry is permissible when a person shows signs of illness with a disease that is classified as dangerous to society or when the person is coming from a region of the world known to be suffering from certain contagious outbreaks. In both cases all passengers arriving on the same mode of transportation must undergo testing. However, such tests may not result in deprivation of liberty, or test-taking or other measures that constitute a physical violation.
Individuals who have potentially been exposed to a communicable disease (but who are not showing signs of disease) may be quarantined “within a facility or area.” Individuals in quarantine or isolation are not allowed to leave the country. Individuals who harbor a disease but are not under isolation or quarantine may leave the country after first notifying the CMO.
4. Quarantine of Certain Areas, Harbors, and Airports
Specific areas may be designated as quarantine areas. The government, or the agency appointed by the government, decides which ports and airports should be deemed “quarantine ports.” However, the government must work together with the county councils and municipalities in this effort. While the government ultimately determines the designation as a quarantine harbor, the county councils and municipalities are responsible for ensuring that the airports and ports in their regions have all the resources they need, as specified by government instruction. The local CMO is responsible for the care of patients and containment of the disease at these harbors. Aircraft and vessels may not be turned away but should instead relocate to the designated quarantine harbor or airport.
D. Powers of Disease Prevention
When the new Communicable Diseases Act was adopted in 2004 its main goal was to emphasize preventing the spread of diseases that are transmitted from human to human. Disease prevention includes vaccination programs as well as educational efforts on how disease is spread.
1. National Vaccination Program and Seasonal Flu Vaccinations
Sweden has a comprehensive, voluntary vaccination program for children, which includes vaccinations against Polio, MMR, DTap, IPV, HiB, PCV, and HPV, and administers free seasonal influenza vaccinations for risk groups as well as a general vaccination program for swine flu. Most Swedes are vaccinated against these diseases. The NBHW oversees the national vaccination program and makes changes as needed. For a vaccine to qualify for placement on the vaccination programs list, it must be “effective, socioeconomically cost effective and sustainable from an ethical and humanitarian ground.” These vaccinations are entered into a “national vaccination database” that tracks the vaccination of Swedish children. The database may be expanded under the supervision and direction of the government to include all vaccinations administered in Sweden.
The NBHW issues recommendations as to who should get a seasonal flu vaccine and has recommended that all pregnant women in their second or third trimester get vaccinated. Other groups who are recommended to get the seasonal flu vaccines include the elderly and those who have underlying conditions, especially respiratory ones.
2. Mandatory Vaccinations
Although vaccinations under the national vaccination program and seasonal flu vaccines are not mandatory, the government may mandate vaccination during times of war and/or in other extraordinary circumstances. Failure to comply with such mandated vaccination may result in a fine as well as a court-mandated vaccination by force backed by the penalty of a fine, which can be reissued. Until 1991 the fine was limited by statute to between SEK 5 (US$.68) and SEK 50 (US$6.80) (unchanged since its initial adoption in 1952); following 1991 amendments the amount of the fine is no longer established by law.
3. Informational/Educational Material
The county councils are responsible for producing and disseminating information on contagious diseases to the public.
4. Forcible Screenings and Tests
A person who is believed to be carrying a communicable disease and opposes testing can be forcibly tested but only at the order of a district administrative court. Only the CMO may petition for the court to issue such an order. Following a petition from the CMO the administrative court must issue a ruling on forcible testing within a week.
E. Sanctions for Noncompliance
Violations of formal instructions required by the Communicable Diseases Act are penalized. A person who intentionally transfers a disease to another can be punished with up to six years in prison. The negligent spreading of a disease is punishable with a fine or imprisonment of up to one year when the person realizes the danger of the spread and does not take precautions to stop it. When no transmission of a disease occurs, the risk alone (if known by the perpetrator) is punishable as “creation of danger to others” with up to two years imprisonment.
Patients who receive treatment have no separate right to compensation for time spent in isolation, etc., but all health care and all medications are free to the patient and not part of the “maximum payment protection” limit, under which health care is only free following the expenditure of a regulated maximum annual fee that a patient may incur. All vaccinations carried out under the Communicable Diseases Act are also free of charge to the patient.
G. Conflicts with Constitutional Rights of Individuals
Treatments for contagious diseases risk creating a conflict between fundamental human rights and health-care measures, as these interventions may limit the patient’s freedoms, including both the treatments in themselves and the collection of personal information used to track and prevent further spread.
1. Treatment of Personal Information/Data
According to the Swedish Personal Information Act, personal information may only be gathered and stored when it is necessary in the practice of preventative care, to make a medical diagnosis, to care for or treat the patient, or to administer health care. The administrator (i.e., the agency that keeps the record of personal information) is required to keep personal information as safe as possible, considering technology, budget, risks, and the sensitivity of the information. When the registration of personal information violates the Personal Information Act, the individual recorded is entitled to damages. Some decisions on the treatment of personal information are appealable to the administrative court system.
The Swedish government collects data on Swedish patients through the vaccination program and also through the sharing of information from the patient’s health record when he or she seeks medical treatment. The Act on Public Information and Secrecy prescribes secrecy for such health information.
A person who has contracted a contagious disease is responsible for cooperating in finding the source of the disease as well as containing the spread of the disease and informing his or her health provider of other potential victims of the disease. This information is classified, and may not be divulged. However, patient information may be shared, regardless of secrecy, in international preventative work. Moreover, the CMO may, against the wishes of a contagious patient, inform his or her family that he or she is a carrier of a disease in efforts to prevent further spread of the disease.
Individuals have the right to know what personal information about them is stored and may submit a request for this information at least once a year.
2. Quarantine and Isolation
Quarantine and isolation are infringements on human rights. Isolation requires prior approval by the courts or in cases of emergency speedy review by the courts. Because Sweden has signed on to the European Convention on Human Rights it is the European Court on Human Rights that establishes the case law on infringement of human rights.
3. Case Law: Right to Freedom (Enhorn v. Sweden)
Isolation of an individual may result in a violation of the patient’s fundamental rights under article 5 of the Convention. In Enhorn v. Sweden, the European Court of Human Rights found that placing the plaintiff in isolation was a breach of his right to liberty and security of person, as guaranteed in article 5 of the European Convention on Human Rights. The case involved an HIV-infected man who, after several breaches of conduct that violated the action plan prescribed by the local CMO, was placed under forced isolation. The European Court of Human Rights found that the isolation violated the plaintiff’s human rights because no less invasive method of preventing the spread of the disease had been considered.
Even before Enhorn,in the legislative history of the 2003 Communicable Diseases Act the Swedish government wrote that the forced isolation of an HIV-positive person is less likely to conform with human rights because transmission of the disease requires intimate contact. It remains unclear whether forced isolation due to a more contagious disease that spreads “by casual contact” is consistent with human rights as guaranteed by the European Convention on Human Rights.
III. Transparency of Public Health Crisis Management System: Publication and Information-sharing Requirements
A. Dissemination of Information to the Public
The government has made available an online platform, Krisinformation.se, that serves as a central clearinghouse for all crisis information.
B. Local Contingency Plans
Each county council is required to have a publicly available local crisis preparedness plan, and to have an official on duty twenty-four hours a day, seven days a week to respond to a potential crisis.
C. Transmission of Information
Sweden has a nationally coordinated communications system called the “VMA system” or the “important message to the public system” and a specialized radio system to communicate heightened preparedness in times of peace. Increased preparedness is communicated by radio and television. The highest level of preparedness is announced through a preparedness alarm. The preparedness alarm is an alarm indicating increased preparedness that is transmitted on facilities for outdoor alarms through thirty-second-long signals with a fifteen-second interval between the signals, for a total of five minutes.
IV. Cooperation with the World Health Organization
The National Board of Health and Welfare is responsible for cooperation with the World Health Organization. Sweden also provides support to local initiatives and has provided resources to fight the Ebola epidemic in West Africa of SEK 139 million (about US$18.7 million) this year.
V. Current Crisis/Recent Developments
Sweden has been spared from recent public health crises. The government-run website Krisinformation.se lists events that qualify as recent national crises. Most are environmental (storms) or animal related (such as salmonella in animal fodder) but there are also some public health threats that could have developed into public health crises but did not—specifically the swine-flu outbreak in 2009, and the bird-flu outbreak in 2006. In addition, the current Ebola threat has the potential to develop into a public health crisis.
A. Swine Flu, 2009
Sweden was first informed of the threat of A(H1N1) (swine flu) in the spring of 2009. Initially, vaccination was recommended for risk groups, but this quickly changed after a pregnant woman died. When the WHO updated the classification of the A(H1N1) to a pandemic (level six on their scale) the pandemic vaccination program automatically came into force, requiring county councils to decide how much vaccine they needed. A total of eight million doses were ordered for the entire country. The infections peaked in October of 2009, with vaccinations initiated a week later, resulting in 11,000 laboratory-verified cases of A(H1N1) for all of 2009. The primary prevention focus was on the national vaccination campaign.
In its 2011 evaluation report the NBHW and Swedish Contingency Agency noted several problems with the swine flu response. First, it found that language barriers proved to be a greater obstacle than expected in portions of the population without Swedish as a primary language. Other problems included difficulties in following the transmission of the disease despite classifying the pandemic as a disease that requires a report to a CMO under the Communicable Diseases Act. Only the Stockholm County Council had a working, automated system for keeping track of the disease. Smaller county councils were especially hard hit in meeting the demands of the increased load of patients. Also, determining the distribution priorities of the initial doses of vaccine and how the public should be informed of it was difficult. Reportedly, the NBHW continues to work with how resources should be distributed during the next pandemic.
Another issue noted in the evaluation report was the lack of coordination in the response, as emergency information was transmitted. Problems that occurred included certain county councils running out of vaccines and antiviral medicine and being unaware of where to order more. Long-term effects of the pandemic response included an unexpectedly large number of children diagnosed with narcolepsy following the use of the vaccine Pandemrix. Intensive care saw a steep increase in influenza patients, especially patients suffering from bronchitis and other respiratory problems. The World Health Organization provides a graph of current influenza statistics.
Overall, the evaluation report found the A(H1N1) response was socioeconomically ineffective, which it attributed mostly to the delay in distributing vaccinations. The report did not take the side-effects (predominantly narcolepsy in children and teenagers) into account when estimating whether the response was efficient. In total, 60% of Sweden’s population was vaccinated. Thirty-one Swedes reportedly died from the virus.
Earlier this year (2014) it was discovered that a mild variant of the swine flu virus (H1N2) had been transmitted between some farmers in Sweden and their pigs, the first time this is known to have occurred in Sweden.
B. Bird Flu, 2006
Sweden was mildly affected by the bird flu virus in 2006. A number of birds but no humans were infected. The outbreak did, however, spur the response and intervention of national and local authorities, and its treatment resulted in a short report by the Swedish Contingency Agency. Coordinated government responses included setting up a public information website, Fagelinfluensa.info, and a round-the-clock telephone service for bird-flu related information and questions. Overall, the response was considered successful.
C. Current Ebola Threat
On October 23, 2014, the government declared Ebola a disease dangerous to society. Despite declaring itself ready to handle an Ebola patient, the NBHW the same evening refused to admit an international Ebola patient on grounds that it did not know what was needed of it. As of yet no Ebola victim has been confirmed in Sweden.
The country is increasing its spending and preparations for fighting the Ebola virus, currently recruiting additional personnel to be sent to Liberia. Sweden is allocating equipment and funding totaling SEK 489 million (about US$66 million) for 2014 to combat Ebola. Extra funding is also being provided as earmarks to the NBHW budget to help coordinate the effort both locally and abroad. Municipalities have raised their preparedness by issuing local guidelines for health care workers encountering Ebola patients at local, non-hospital, health-care facilities.
The Swedish Armed Forces has reported that it is prepared to fly an Ebola patient from Africa to Sweden within twenty-four hours. The transport would include a custom-made ambulance carried inside a Hercules airplane. There is no information on how long it would take to get the aircraft from Sweden to Africa.
D. National Preparedness and Effectiveness of Routines
A governmental study conducted following the bird flu outbreak resulted in recommendations to improve the cooperation between inpatient care, primary care, and municipal care, and to focus more heavily on logistical aspects, plans to secure resources, and preparedness within the individual communicable diseases units. Also, the European Center for Disease Prevention and Control’s (ECDC’s) investigation in 2007 found that local preparedness could be improved. The level of local preparedness was effectively tested during the 2009 response to the potential swine-flu pandemic. The response was investigated and culminated in a report in 2011 in which the experts found that improvement efforts should continue to focus on coordination between national and local authorities.
Prepared by Elin Hofverberg
Foreign Law Research Consultant
 Note: Swedish authorities and agencies often change names as a result of government changes, and there was such a government change in September of 2014. The names of relevant state authorities used in this report reflect the names in force in October 2014.
 Regeringsformen [RF] [Constitution] 1:1 para. 2.
 For municipalities’ general responsibilities, see Kommunallag (SFS 1991:900), http://www.riksdagen.se/sv/ Dokument-Lagar/Lagar/Svenskforfattningssamling/Kommunallag-1991900_sfs-1991-900/.
 Smittskyddslagen [Communicable Diseases Act] (Svensk Författningssamling [SFS] 2004:168).
 Ch. 2:2 § Kommunallagen.
 Tre grundprinciper, Krisinformation.se (Dec. 13, 2012), http://www.krisinformation.se/web/Pages/Page____ 11261.aspx.
 Ch. 1:3 para. 1 § Smittskyddslagen.
 Id. ch. 1:3 para. 2 §.
 Id. ch. 1:3 para. 3 § (in Swedish: smittsamma sjukdomar, allmänfarliga sjukdomar, and samhällsfarliga sjukdomar) (translation by author).
 Id. ch. 1:3 para. 1 § SML.
 Id. ch. 1:3 para. 2 § SML (translation by author).
 Id. ch. 1:3 para. 3 § SML.
 Socialstyrelsens Författningssamling (SOSFS) 2012:2 (M) Föreskrifter, Smittspårningspliktiga sjukdomar [Instructions, Communicable Diseases Which Require Tracing], http://www.socialstyrelsen.se/Lists/Artikelkatalog/ Attachments/18593/2012-2-7.pdf.
 Ch. 1:3 para. 3 § Smittskyddslagen (translation by author).
 Smittskyddslagen add. 1.
 Press Release, Regeringskansliet, Regeringsbeslut möjliggör fler skyddsåtgärder mot Ebola [Government Decision Enables Additional Safety Precautions Against Ebola] (Oct. 23, 2014), http://www.regeringen.se/sb/d/ 14850/a/248949.
 See Part II(D) & (E), below.
 Lag om skydd mot internationella hot mot människors hälsa [Act on Protection Against International Threats to People’s Health] (SFS 2006:1570).
 Id. 4–5 §§.
 Press Release, Regeringskansliet, supra note 16.
 2 para. 3 § Lag om skydd mot internationella hot mot människors hälsa.
 Id. 2 para. 2 §.
 Id. 10 §.
 Id. 11 §.
 Id. 9 §.
 Id. 12 §.
 Id. 26 §. For more information on the Health and Social Care Inspectorate, see About the Health and Social Care Inspectorate, IVO, http://www.ivo.se/om-ivo/about-health-and-social-care-inspectorate/Sidor/default.aspx (last visited Oct. 31, 2014).
 32 § Lag om skydd mot internationella hot mot människors hälsa.
 Lag om kommuners och landstings åtgärder inför och vid extraordinära händelser i fredstid och vid förhöjd beredskap [Act on Municipalities and County Councils Measures Ahead of and During Extraordinary Events During Peace Time and Times of Heightened Preparedness] (SFS 2006:544).
 Ch. 2:2 § Lag om kommuners och landstings åtgärder inför och vid extraordinära händelser i fredstid och vid förhöjd beredskap.
 7 § Förordning om krisberedskap och höjd beredskap.
 Id. 5 §.
 Id. 9 §.
 Id. 9 para. 2 §.
 Note that Sweden underwent a change in government in September of 2014 and that the new government may make changes to the organization of its government agencies responsible for public crises. No such changes have yet been announced, however.
 Ch. 1: 7-10 Smittskyddslagen.
 Ch. 1:7 para. 2 § Smittskyddslagen.
 Förordning med instruktion för Myndigheten för samhällsskydd och beredskap [Regulation with Instruction for the Swedish Civil Contingencies Agency] (SFS 2008:1002), http://www.riksdagen.se/sv/Dokument-Lagar/Lagar/Svenskforfattningssamling/Forordning-20081002-med-ins_sfs-2008-1002/.
 Ch. 1:7 § Smittskyddslagen.
 Id. ch. 2:7 §.
 NBHW, Rekommendation för handläggning av misstänkta fall av ebola – reviderad version 2014-09-26 [Recommendations for the handling of suspected ebola cases – revised Sept. 26, 2014], http://www.socialstyrelsen. se/Lists/Artikelkatalog/Attachments/19458/2014-6-7.pdf.
 Lag om skydd mot internationella hot mot människors hälsa (SFS 2006:1570).
 Myndigheten för samhällsskydd och beredskap, Krisinformation.se (Sept. 8, 2011), http://www.kris information.se/web/Pages/Page____72962.aspx.
 Ch. 1: 8 § Smittskyddslagen.
 Id. ch. 1:9 §.
 2b§ Hälso- och sjukvårdslag (SFS 1982:763).
 Ch. 1:8 § Smittskyddslagen.
 Id. ch. 6:1 §.
 Id. ch. 6:2 §.
 Id. ch. 6:6 §, ch. 6:8 §.
 Id. 9b §.
 For information on the operations of the High Risk Unit, see Högisoleringsenheten, Landstinget i Östergötland (Oct. 14, 2014), http://www.lio.se/Om-landstinget/Vard-i-varldsklass/Hogisoleringsenheten/.
 Id. (translation by author).
 Linköping i fokus om Sverige får ett ebolafall, Läkartidningen (Aug. 15, 2014), http://www.lakartidningen. se/Aktuellt/Nyheter/2014/08/Linkoping-i-fokus-om-Sverige-far-ett-misstankt-ebolafall-/.
 Landstinget i Östergötland, supra note 61.
 Nordic Public Health Preparedness Agreement, available at http://www.nordhels.org/Global/Nordhels/avtal/ Nordiskt%20h%C3%A4lsoberedskapsavtal%20-%20engelska.pdf. For example, see information on burn victims at Brännskadevård vid katastrofläge, Akademiska sjukhuset,http://www.akademiska.se/sv/Verksamheter/ Brannskadecentrum/Brannskadevard-vid-katastroflage/ (last visited Oct. 31, 2014).
 Nordic Public Health Preparedness Agreementart. 4.1.
 Id. art. 4.1.
 Id. art. 4.2.
 Id. art. 4.3.
 Id. art. 4.4.
 Id. art. 4.5.
 Id. art. 4.6.
 Id. art. 3.
 See, e.g., Nordic Cooperation Following Dramatic Increase in Tick-borne Infections, University of Gothenburg (Nov. 28, 2012), http://www.sahlgrenska.gu.se/english/news_and_events/news/News_Detail//nordic-cooperation-following-dramatic-increase-in-tick-borne-infections.cid1108094.
 Fjorton förslag om ökat nordiskt samarbete inom sjukvården, LIFe-time.se (June, 16, 2014), http://www.life-time.se/2014/06/16/fjorton-forslag-om-okat-nordiskt-samarbete-inom-sjukvarden/.
 Norden, Patient Mobility in the Nordic Countries (June 2011), http://www.nordicinnovation.org/Global/_ Publications/Reports/2011/2011_patientMobility_report.pdf.
 Prop. 2003/04:30 at 72.
 Id. ch. 3:8 para. 2 § and ch. 3:10 §; see also Part II(D)(4), below.
 Id. ch. 6:3 §.
 Id. ch. 3:2 §.
 Id. ch. 4:3 §.
 Id. ch. 5:2 §.
 Id. ch. 5:3 §.
 Id. ch. 3:8 para. 1 § and ch. 3:9 §.
 Id. ch. 4:9 §.
 For full list, see Communicable Diseases Act add. 1 & 2.
 Ch. 2:5 § Smittskyddslagen.
 Id. ch. 2:5 para. 2 §. See also Anmälan av anmälningspliktig sjukdom i vissa fall (Socialstyrelsens föreskrifter [SOSF] 2007:1), as amended, http://www.socialstyrelsen.se/sosfs/2007-1 (specifically stating in article 3 that A(H1N1) influenza should be reported by treating physicians and a micro-lab technicians, but that pathologists need not report the illness).
 Ch. 2:6 § Smittskyddslagen.
 Marie Jönsson, Comment 25, Comment to Act 2004:168, in 2 Karnov Svensk Lagsamling med kommentarer at 2690 (Cecila Bergman et al. eds., 16th ed. 2011/2012).
 Ch. 3:1 § Smittskyddslagen.
 Karnov, supra note 91, Comment 27 at 2691.
 Ch. 3:4 § Smittskyddslagen.
 16 § Lag om skydd mot internationella hot mot människors hälsa.
 See discussion, Part II(C)(2)–(4), infra.
 Ch. 1:4 § Smittskyddslagen.
 Id. ch. 4:2 §.
 Id. ch. 5:1 para. 1 item 2 §.
 Id. 4:2 §.
 Id. (translation by author).
 Id. ch. 5:1 para. 1 item 2 & ch. 5:1 para. 2 §.
 Id. ch. 5:5 §.
 Id. ch. 5:9–10 §.
 Id. ch. 5:10 §.
 Id. ch. 5:1 §.
 Id. ch. 5:1 para. 2 §.
 Enhorn v. Sweden, App. No. 56529/00 paras. 55–64 (Eur. Ct. H.R. Jan. 25, 2005), http://hudoc.echr.coe.int/ sites/eng/pages/search.aspx?i=001-68077; see also discussion, Part II(G)(3), infra.
 Ch. 3:8 para. 1 & 2 § Smittskyddslagen.
 Id. ch. 3:8 para. 3 §.
 Prop. 2003/04:158 Extraordinära smittskyddsåtgärder at 105.
 Id. ch. 3:9 §.
 Id. ch. 3:12 para. 1–2 §.
 Id. ch. 3: 12 para. 3 §.
 Ch. 3:10 § Smittskyddslagen.
 6 para. 2 § Lag om skydd mot internationella hot mot människors hälsa.
 Id. 6 §.
 Id. 7 §.
 Id. 8 §.
 Id. 18 §.
 Comment, Marie Jönsson, in Karnov, supra note 91, at 2689.
 Childhood Vaccination Schedule, Euvacnet, http://www.euvac.net/graphics/euvac/vaccination/sweden.html (last visited Oct. 31, 2014).
 Ch. 2:3 Smittskyddslagen.
 Id. For statistics on how many Swedes are actually vaccinated, see WHO Vaccine-preventable Diseases: Monitoring System, 2014 Global Summary, World Health Organization, http://apps.who.int/immunization_ monitoring/globalsummary/countries?countrycriteria%5Bcountry%5D%5B%5D=SWE (last visited Oct. 31, 2014).
 Ch. 2:3d § Smittskyddslagen.
 Vaccinationsregister, Folkhälsomyndigheten (June 27, 2014), http://www.folkhalsomyndigheten.se/ amnesomraden/smittskydd-och-sjukdomar/vaccinationer/vaccinationsregister/.
 Frågor & svar, Smittskyddsinstitutet (now Folkhälsomyndigheten), http://www.folkhalsomyndigheten. se/documents/smittskydd-sjukdomar/vaccinationer/faq-vaccinationsregistret.pdf?epslanguage=sv (last visited Oct. 31, 2014).
 Gravida kvinnor rekommenderas vaccination mot säsongsinfluensa [Pregnant Women Recommended to Get Vaccination Against Seasonal Flu], Socialstyrelsen, http://www.socialstyrelsen.se/smittskydd/sjukdomar/ influensa/gravidakvinnor (last visited Oct. 31, 2014).
 Riksgrupper för årlig influensa [Risk Groups for Seasonal Flu], Socialstyrelsen, http://www.socialstyrelsen. se/smittskydd/sjukdomar/influensa/riskgrupper (last visited Oct. 31, 2014).
 Lag om skyddsympning vid krig eller krigsfara m.m. [Act on Preventative Vaccination During War or Threat of War] (SFS 1952:270); Proposition (Prop.) 2003/04:30 Ny smittskyddslag at 103.
 3 § Lag om skyddsympning vid krig eller krigsfara m.m.
 Prop. 1990/91:68 Om ändringar i brottsbalken (böter) m.m. [Regarding Changes in the Criminal Code (fines) etc.] [Government Bill], http://www.riksdagen.se/sv/Dokument-Lagar/Forslag/Propositioner-och-skrivelser/om-andring-i-brottsbalken-mm_GE0368/ (adopting SFS 1991:271).
 Ch. 2:3 § Smittskyddslagen.
 Id. ch. 3:2 §.
 Id. ch. 8:5 item 1 §.
 See discussion, Part II(D)(1), supra.
 Ch. 13:7 § Brottsbalken [Criminal Code] (SFS 1962:700).
 Id. ch. 13: 10 §.
 Id. ch. 3:9 § BRB; see also Nytt Juridiskt Arkiv [NJA] [Supreme Court Reports] 2004 p. 176 B4189-03, where the defendant was HIV positive and was indifferent as to the risk of spreading the disease to his sexual partners.
 Ch. 7:1-2 § Smittskyddslag.
 Id. ch. 7: 2a § (referencing the national vaccination program).
 18 § Personuppgiftslagen [PUL] [Personal Information Act] (SFS 1998:204).
 31 § PUL.
 48 § PUL.
 51, 52, 53 §§ PUL.
 Ch. 1:6 § (for provisions, see chapter 25) Offentlighets- och sekretesslag [Act on Public Information and Secrecy] (SFS 2009:400).
 Ch. 2:2 § and ch. 3:4 § Smittskyddslagen.
 Lag om skydd mot internationella hot mot människors hälsa (SFS 2006:1570).
 Ch. 4:8 § Smittskyddslag.
 26 § PUL.
 See ch. 5:2 § and ch. 5:3 § Smittskyddslag.
Enhorn v. Sweden, App. No. 56529/00 paras. 55–64 (Eur. Ct. H.R. Jan. 25, 2005), http://hudoc.echr.coe.int/ sites/eng/pages/search.aspx?i=001-68077
 Id. paras. 8–26.
 Id. paras. 55–56.
 Prop. 2003/04:30 at 75.
 Vilket ansvar har landstingen när det gäller beredskapen mot ebola?, Krisinformation.se (Sept. 2, 2014), http://www.krisinformation.se/web/Pages/Faq/ShowFaqWithLeftMenu____75516.aspx?FaqId=0470029& LangID=SV.
 See, e.g., Krishanteringsplan, Stockholms Läns Landsting (Apr. 7, 2009), http://www.sll.se/Global/Om %20landstinget/Krisberedskap/krishanteringsplan-stockholms-lans-landsting.pdf.
 53 § Förordning med länsstyrelseinstruktion [Instruction for the County Administrative Board] (SFS 2007:825).
 VMA – Viktigt meddelande till allmänheten, MSB (Sept. 29, 2009), https://www.msb.se/sv/Insats--beredskap/Hantera-olyckor--kriser/VMA/.
 23 § Förordning om krisberedskap och höjd beredskap.
 Id. 24 §.
 11 § Lag om skydd mot internationella hot mot människors hälsa.
 As determined by the government-run site Krisinformation.se. Influensa A(H1N1) 2009, även kallad svininfluensan, Krisinformation.se (Aug. 2, 2012), http://www.krisinformation.se/web/Pages/SubStart Page____72951.aspx.
 Socialstyrelsen, Influensa A(H1N1) 2009: Utvärdering av förberedelser och hantering av pandemin 10 (Feb. 2011), http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/18243/2011-3-3.pdf.
 Id. at 10.
 Id. at 13.
 Id. at 14.
 Id. at 17.
 Id. at 18.
 Id. at 73-75.
 Id. at 12.
 Chart, Number of Specimens Positive for Influenza by Subtype – Sweden, WHO (Nov. 12, 2014), http://gamapserver.who.int/gareports/Default.aspx?ReportNo=1&CountryCode=SE.
 Socialstyrelsen, supra note 167, at 93.
 For an overview in English, see Statement on Narcolepsy and Vaccination, WHO (Apr. 21, 2011), http://www.who.int/vaccine_safety/committee/topics/influenza/pandemic/h1n1_safety_assessing/narcolepsy
_statement/en/; see also Francesca Poli et al., Narcolepsy as an Adverse Event Following Immunization: Case Definition and Guidelines for Data Collection, Analysis and Presentation, Elsevier (Dec. 16, 2012), http://www.who.int/ vaccine_safety/initiative/BC_Narcolepsy_case_definition.pdf?ua=1.
 Socialstyrelsen, supra note 167, at 64.
 Id.at 57.
 Swedish Farmers Contracted Swine Flu, TheLocal.se (Oct. 22, 2014), http://m.thelocal.se/20141022/swedish-farmers-contracted-swine-flu.
 Utbrottet av fågelinfluensa i Sverige 2006, Krisinformation.se (Aug. 2, 2012), http://www.krisinformation. se/web/Pages/Page____55168.aspx.
 Fågelinfluensa, Krisinformation.se (July 4, 2011), http://www.krisinformation.se/web/Pages/Page____ 31992.aspx.
 Utbrotten av fågelinfluensa i Sverige 2006, Krisberedskapsmyndigheten (now the Swedish Contingencies Agency) (Dec. 7, 2006), http://www.krisinformation.se/web/Upload/Krisinformation.se/Handelser/F%c3%a5 gelinfluensan/utbrotten_av_fagelinfluensa_2006.pdf.
 Fågelinfluensa, Krisinformation.se (July 4, 2011), http://www.krisinformation.se/web/Pages/Page____ 31992.aspx.
 Id. at 36.
 Press Release, Regeringskansliet, supra note 16.
 Landstinget i Östergötland vägrade ta emot ebolasjuk, Corren.se (Oct. 24, 2014), http://www.corren.se/nyheter/ ostergotland/sverige-ville-inte-varda-ebolasjuk-7455211.aspx.
 Utökade Svenska Insatser i Västafrika, Socialstyrelsen (Oct. 9, 2014), http://www.socialstyrelsen.se/nyheter/ 2014oktober/utokadesvenskainsatserivastafrika.
 Ytterligare 400 miljoner till ebolabekämpning och humanitära kriser [Additional SEK 400 Million to the Fight Against Ebola and Humanitarian Crisises], Regeringskansliet (Oct. 24, 2014), http://www.regeringen.se/ sb/d/18915/a/248832; Sveriges stöd i kampen mot Ebola [Swedish Support in the Fight Against Ebola], Regeringskansliet (Oct. 23, 2014), http://www.regeringen.se/content/1/c6/24/88/32/94c6596e.pdf.
 Sveriges stöd i kampen mot Ebola, supra note 193; Utökade Svenska Insatser i Västafrika, Socialstyrelsen (Oct. 9, 2014), http://www.socialstyrelsen.se/nyheter/2014oktober/utokadesvenskainsatserivastafrika.
 See, e.g., Vårdhygien Östergötland,EBOLA – lokalt PM för omhändertagande av misstänkt ebola-smittad patient (Oct. 21, 2014), http://vardgivarwebb.lio.se/pages/248565/EBOLA.pdf.
 Förberedda att flyga ebolapatient, Försvarsmakten (Oct. 9, 2014), http://www.forsvarsmakten.se/ sv/aktuellt/2014/10/forberedda-att-flyga-ebolapatient/.
 See Socialstyrelsen, supra note 167, at 8.
 See Part V(A), supra.
Last Updated: 06/09/2015