The one-sided explanations of a multifactorial coronavirus disease.

Short-term interventions to suppress COVID-19 completely dominate the public, political and even the professional discussion on what explains observed differences in mortality and morbidity across countries. This leads to an exaggerated view of what such measures can accomplish. Factors such as housing and social conditions as well as travel patterns are equally important but neglected aspects of the COVID-19 development. A multifactorial disease needs a multivariate analytical approach.

Interventions to suppress the coronavirus pandemic will increase unemployment and lead to many premature deaths.

BACKGROUND AND AIMS: Interventions to suppress the coronavirus pandemic have led to economic recession and higher unemployment, which will increase mortality and decrease quality of life. The aim of this article is to estimate the consequences on mortality and life expectancy of increased unemployment rates due to the coronavirus pandemic in Sweden and other countries. METHODS: Based on recent increases and expected future unemployment rates due to the coronavirus pandemic, results from a systematic review and data from vital statistics in Sweden, the number of premature deaths due to unemployment in Sweden have been estimated. RESULTS: Based on our assumptions, the calculations show that if the number of unemployed persons in Sweden increases by 100,000, one may expect some 1800 more premature deaths during the following 9 years. If the duration of the recession is limited to 4 years, excess deaths due to unemployment may be around 800. On average, the unemployed will lose 2 years of their remaining life expectancy. In many other countries unemployment rates have or are estimated to rise more than in Sweden, sometimes two- or threefold, suggesting hundreds of thousands of excess deaths due to unemployment. CONCLUSIONS: Interventions to suppress the coronavirus pandemic include the shut-down of economic activities and lead to increased all-cause mortality. These public health effects must be considered in the decision-making process and should be added to overall estimates of the effects of the pandemic on public health.

Earnings among people with multiple sclerosis compared to references, in total and by educational level and type of occupation: a population-based cohort study at different points in time.

OBJECTIVES: To investigate earnings among people with multiple sclerosis (PwMS) before and after MS diagnosis compared with people without MS, and if identified differences were associated with educational levels and types of occupations. Furthermore, to assess the proportions on sickness absence (SA) and disability pension (DP) in both groups. DESIGN: Population-based longitudinal cohort study, 10 years before until 5 years after MS diagnosis. SETTING: Working-age population using microdata linked from nationwide Swedish registers. PARTICIPANTS: Residents in Sweden in 2004 aged 30-54 years with MS diagnosed in 2003-2006 (n=2553), and references without MS (n=7584) randomly selected by stratified matching. OUTCOME MEASURES: Quartiles of earnings were calculated for each study year prior to and following the MS diagnosis. Mean earnings, by educational level and type of occupation, before and after diagnosis were compared using t-tests. Tobit regressions investigated the associations of earnings with individual characteristics. The proportions on SA and/or DP, by educational level and type of occupation, for the diagnosis year and 5 years later were compared. RESULTS: Differences in earnings between PwMS and references were observed beginning 1 year before diagnosis, and increased thereafter. PwMS had lower mean earnings for the diagnosis year (difference=SEK 28 000, p<0.05), and 5 years after diagnosis, this difference had more than doubled (p<0.05). These differences remained after including educational level and type of occupation. Overall, the earnings of PwMS with university education and/or more qualified occupations were most like their reference peers. The proportions on SA and DP were higher among PwMS than the references. CONCLUSIONS: The results suggest that the PwMS' earnings are lower than the references' beginning shortly before MS diagnosis, with this gap increasing thereafter. Besides SA and DP, the results indicate that educational level and type of occupation are influential determinants of the large heterogeneity of PwMS' earnings.

Avoidable cancers in the Nordic countries-the potential impact of increased physical activity on postmenopausal breast, colon and endometrial cancer.

BACKGROUND: Physical activity has been shown to reduce the risk of colon, endometrial and postmenopausal breast cancer. The aim of this study was to quantify the proportion of the cancer burden in the Nordic countries linked to insufficient levels of leisure time physical activity and estimate the potential for cancer prevention for these three sites by increasing physical activity levels. METHODS: Using the Prevent macrosimulation model, the number of cancer cases in the Nordic countries over a 30-year period (2016-2045) was modelled, under different scenarios of increasing physical activity levels in the population, and compared with the projected number of cases if constant physical activity prevailed. Physical activity (moderate and vigorous) was categorised according to metabolic equivalents (MET) hours in groups with sufficient physical activity (15+ MET-hours/week), low deficit (9 to <15 MET-hours/week), medium deficit (3 to <9 MET-hours/week) and high deficit (<3 MET-hours/week). RESULTS: If no one had insufficient levels of physical activity, about 11,000 colon, endometrial and postmenopausal breast cancer cases could be avoided in the Nordic countries in a 30-year period, which is 1% of the expected cases for the three cancer types. With a 50% reduction in all deficit groups by 2025 or a 100% reduction in the group of high deficit, approximately 0.5% of the expected cases for the three cancer types could be avoided. The number and percentage of avoidable cases was highest for colon cancer. CONCLUSION: 11,000 cancer cases could be avoided in the Nordic countries in a 30-year period, if deficit in physical activity was eliminated.

Rationale for a Swedish cohort consortium.

We herein outline the rationale for a Swedish cohort consortium, aiming to facilitate greater use of Swedish cohorts for world-class research. Coordination of all Swedish prospective population-based cohorts in a common infrastructure would enable more precise research findings and facilitate research on rare exposures and outcomes, leading to better utilization of study participants' data, better return of funders' investments, and higher benefit to patients and populations. We motivate the proposed infrastructure partly by lessons learned from a pilot study encompassing data from 21 cohorts. We envisage a standing Swedish cohort consortium that would drive development of epidemiological research methods and strengthen the Swedish as well as international epidemiological competence, community, and competitiveness.

Socioeconomic disparities associated with 29 common infectious diseases in Sweden, 2005-14: an individually matched case-control study.

BACKGROUND: Although the association between low socioeconomic status and non-communicable diseases is well established, the effect of socioeconomic factors on many infectious diseases is less clear, particularly in high-income countries. We examined the associations between socioeconomic characteristics and 29 infections in Sweden. METHODS: We did an individually matched case-control study in Sweden. We defined a case as a person aged 18-65 years who was notified with one of 29 infections between 2005 and 2014, in Sweden. Cases were individually matched with respect to sex, age, and county of residence with five randomly selected controls. We extracted the data on the 29 infectious diseases from the electronic national register of notified infections and infectious diseases (SmiNet). We extracted information on country of birth, educational and employment status, and income of cases and controls from Statistics Sweden's population registers. We calculated adjusted matched odds ratios (amOR) using conditional logistic regression to examine the association between infections or groups of infections and place of birth, education, employment, and income. FINDINGS: We included 173 729 cases notified between Jan 1, 2005, and Dec 31, 2014 and 868 645 controls. Patients with invasive bacterial diseases, blood-borne infectious diseases, tuberculosis, and antibiotic-resistant infections were more likely to be unemployed (amOR 1·59, 95% CI 1·49-1·70; amOR 3·62, 3·48-3·76; amOR 1·88, 1·65-2·14; and amOR 1·73, 1·67-1·79, respectively), to have a lower educational attainment (amOR 1·24, 1·15-1·34; amOR 3·63, 3·45-3·81; amOR 2·14, 1·85-2·47; and amOR 1·07, 1·03-1·12, respectively), and to have a lowest income (amOR 1·52, 1·39-1·66; amOR 3·64, 3·41-3·89; amOR 3·17, 2·49-4·04; and amOR 1·2, 1·14-1·25, respectively). By contrast, patients with food-borne and water-borne infections were less likely than controls to be unemployed (amOR 0·74, 95% CI 0·72-0·76), to have lower education (amOR 0·75, 0·73-0·77), and lowest income (amOR 0·59, 0·58-0·61). INTERPRETATION: These findings indicate persistent socioeconomic inequalities in infectious diseases in an egalitarian high-income country with universal health care. We recommend using these findings to identify priority interventions and as a baseline to monitor programmes addressing socioeconomic inequalities in health. FUNDING: The Public Health Agency of Sweden.

Avoidable cancers in the Nordic countries-The impact of alcohol consumption.

BACKGROUND: Alcohol consumption is an important and preventable cause of cancer. The aim of this study was to quantify the proportion of the cancer burden in the Nordic countries linked to alcohol and estimate the potential for cancer prevention by changes in alcohol consumption. METHODS: Using the Prevent macro-simulation model, the number of cancer cases in the Nordic countries over a 30-year period (2016-2045) was modelled for six sites, under different scenarios of changing alcohol consumption, and compared to the projected number of cases if constant alcohol consumption prevailed. The studied sites were colorectal, post-menopausal breast, oral cavity and pharynx, liver, larynx as well as oesophageal squamous cell carcinoma. The alcohol consumption was based on the categories of non-drinkers/occasional drinkers, light drinkers (<=12.5 g alcohol per day), moderate drinkers (>12.5 and ≤ 50 g/day) and heavy drinkers (>50 g/day). RESULTS: About 83,000 cancer cases could be avoided in the Nordic countries in a 30-year period if alcohol consumption was entirely eliminated, which is 5.5% of the expected number of cases for the six alcohol-related cancer types. With a 50% reduction in the proportion with moderate alcohol consumption by year 2025, 21,500 cancer cases could be avoided. The number of avoidable cases was highest for post-menopausal breast and colorectal cancer, but the percentage was highest for oesophageal squamous cell carcinoma. CONCLUSION: The results from this study can be used to understand the potential impact and significance of primary prevention programmes targeted towards reducing the alcohol consumption in the Nordic countries.

Tackling the tobacco epidemic in the Nordic countries and lower cancer incidence by 1/5 in a 30-year period-The effect of envisaged scenarios changing smoking prevalence.

BACKGROUND: Tobacco smoking is a leading cause of cancer and the most preventable cause of cancer worldwide. The aim of this study was to quantify the proportion of the cancer burden in the Nordic countries linked to tobacco smoking and estimate the potential for cancer prevention by changes in smoking prevalence. METHODS: The Prevent macro-simulation model was used, estimating the future number of cancer cases in the Nordic countries over a 30-year period (2016-2045), for 13 cancer sites, under different scenarios of changing smoking prevalence, and compared to the projected number of cases if constant prevalence prevailed. RESULTS: A total of 430,000 cancer cases, of the 2.2 million expected for the 13 studied cancer sites, could be avoided in the Nordic countries over the 30-year period if smoking was eliminated from 2016 onwards. If prevalence of smoking is reduced to 5% by year 2030 and to 2% by 2040, 230,000 cancer cases could be avoided. The largest proportion of cancers can be avoided in Denmark, where smoking prevalence is the highest, and similar to the prevalence in many European countries. CONCLUSION: A large amount of cancers could be avoided in the Nordic countries if smoking prevalence was reduced. The results from this study can be used to understand the potential impact and significance of primary prevention programmes targeted towards reducing the prevalence of tobacco smoking in the Nordic countries.

Avoidable cancer cases in the Nordic countries - The impact of overweight and obesity.

BACKGROUND: Several types of cancers are causally linked to overweight and obesity, which are increasing in the Nordic countries. The aim of this study was to quantify the proportion of the cancer burden linked to overweight and obesity in the Nordic countries and estimate the potential for cancer prevention. METHODS: Under different prevalence scenarios of overweight and obesity, the number of cancer cases in the Nordic countries in the next 30 years (i.e. 2016-2045) was estimated for 13 cancer sites and compared to the projected number of cancer cases if the prevalence stayed constant. The Prevent macro-simulation model was used. RESULTS: Over the period 2016-2045, 205,000 cancer cases out of the 2.1 million expected for the 13 cancer sites (9.5%) that have been studied, could be avoided in the Nordic countries by totally eliminating overweight and obesity in the target population. The largest proportional impact was found for oesophageal adenocarcinoma (24%), and the highest absolute impact was observed for colon (44638) and postmenopausal breast cancer (41135). CONCLUSION: Decreased prevalence of overweight and obesity would reduce the cancer burden in the Nordic countries. The results from this study form an important step to increase awareness and priorities in cancer control by controlling overweight and obesity in the population.

Sickness absence and subsequent disposable income: A population-based cohort study.

AIMS: Studies show a negative association between an absence from work due to disease of injury (sickness absence (SA)) and subsequent earnings; however, little is known about the association between SA and an individuals' subsequent overall economic welfare. Our primary objective was to evaluate individuals' disposable income (DI) following a spell of SA. Our secondary objective was to examine if the potential association between SA and DI differs, depending on the diagnosis given to that sickness or the duration of the SA spell. METHODS: We used a cohort based on a linked individual register database that includes all individuals living in Sweden from 2001 to 2005, aged 30-54. DI was measured 2-6 years after a spell of SA and compared with a propensity score-matched reference group (individuals without SA in 2005). Each year of follow-up during 2007-2011 was estimated by linear regression for three different forms of exposure: SA (yes/no), diagnosis specific (cancer, circulatory, injuries, musculoskeletal or mental illnesses), and by duration of the SA spell (15-29, 30-89, 90-179 or > 179 days). RESULTS: Individuals with SA during 2005 had 4% lower disposable income in subsequent years than the reference group. Our results were similar across diagnoses, except for mental diagnoses, where disposable income was 7-10% lower than the reference group; and for cancer, where we found only a marginal difference among those with SA and the reference group. Furthermore, DI was negatively associated with the SA spell duration. CONCLUSIONS: SA was associated with lower subsequent DI, 2­6 years after a SA spell, especially after a mental illness diagnosis and if the SA was for longer spells.

Sources and level of income among individuals with multiple sclerosis compared to the general population: A nationwide population-based study.

INTRODUCTION: Multiple sclerosis (MS) is associated with reduced work capacity, but there is limited knowledge about MS patients' sources of income. OBJECTIVES: The purpose of this study was to elucidate MS patients' earnings and social benefits compared to those of the general population. METHODS: From nationwide registers of all residents in Sweden aged 21-64 years in 2010 (n=5,291,764), those with an MS diagnosis (n=13,979) were compared to a propensity score matched reference group (n=69,895). Descriptive statistics and regression models were used to estimate the percentage difference between the MS patients and the matched references regarding the following annual incomes: earnings, disability pension, sickness absence, disability allowance, unemployment compensation and social assistance. RESULTS: Both MS patients and the matched references received most of their income from earnings followed by disability pension and sickness absence. MS patients that were diagnosed in 2010 had 15% lower earnings than the matched references, while MS patients diagnosed before 2005 had 38% lower earnings. Corresponding figures regarding summed social benefits were 33% and 130% higher for MS patients, respectively. CONCLUSION: The results indicate that MS patients are overrepresented, in relative and absolute terms, regarding health-related benefits and have lower levels of earnings. However, the redistributing welfare systems appear to financially compensate the MS patients considerably.

The association of snus and smoking behaviour: a cohort analysis of Swedish males in the 1990s.

BACKGROUND: The European Union has banned sales of moist snuff (snus) in all member states, with the exception of Sweden. The ban is motivated by the potential adverse health effects of snus, but snus may also help people to avoid smoking or stop tobacco use. AIMS: The purpose of this study is to investigate the association between snus and smoking behaviour. MEASUREMENTS: The Swedish Survey of Living Conditions (ULF) health interview panel running from 1988/9 to 1996/7 was used to examine the gross and net flows between smoking and snus among Swedish males. Females were excluded from the analysis due to low snus prevalence. Contingency table models were used to investigate several hypotheses about the relationships between snus and smoking behaviour. FINDINGS: We found clear associations between the two habits. For the younger cohort (age 16-44 years), snus use contributed to approximately six smoking quitters per smoking starter attributable to snus. For the older cohort (age 45-84) there were slightly more than two quitters per starter. In terms of odds ratios, in the younger group smoking cessation attributable to snus was twice as common as smoking initiation, but in the older group the odds of starting smoking attributable to snus was 2.5 times higher than for quitting. CONCLUSIONS: Snus contributed to the reduction of smoking among Swedish males in the 1990s. Snus had different effects among non-smokers and smokers in different age groups.

Is moist snuff use associated with excess risk of IHD or stroke? A longitudinal follow-up of snuff users in Sweden.

BACKGROUND: The potential risks of Swedish moist snuff (snus) are debated and studies have shown diverging results. AIMS: The aim of this study is to investigate whether there is any excess risk of ischaemic heart disease (IHD) and stroke from snuff use. METHODS: The Swedish Survey of Living Conditions from 1988-89 was record-linked to the Swedish Cause of Death Register and the Swedish Hospital Discharge Register to investigate excess mortality and hospitalization from IHD and stroke. A Poisson regression model was used and incidence rate ratios (IRRs) for snuff and smoking were calculated controlling for age, physical activity, self-reported health, number of longstanding illnesses, residential area, and socioeconomic position. RESULTS: Among snuff users there were no excess risks of mortality or hospitalization from IHD (IRR 0.8; 0.5-1.2,) or stroke (IRR 1.1; 0.7-1.8), but, as expected, clear excess risks were found for smokers (IRR 1.7; 1.4-2.1 for IHD, and IRR 1.4; 1.0-1.9 for stroke). CONCLUSIONS: This study has not shown any excess risk among users of snuff for IHD or stroke. If there is a risk associated with snuff it is evidently much lower than those associated with smoking.