Fear sells

Living in Stockholm is dangerous, at least you can easily get that impression. No, today I’m not going to talk about Covid-19, today I’m going to talk about another danger.

It lurks in the wilderness and jumps on you when you walk by and sucks your blood.

It’s less than 5 mm long.

It’s a tick. 

A tick lurking for a host to come by. Copyright Leroy Baptiste

If you have walked in a forest, especially in the late spring/early summer after rain, you have probably encountered it.

Ticks can transfer diseases. One of them — just like Covid-19 — is a disease for which there is no known cure: Tick-borne encephalitis or TBE. There is, however, a vaccine.

If you live in Stockholm, it is very hard to not know this. Big billboards next to busstops, in the subway, and over super market entrances will remind you every spring and summer.

A flyer I picked up at a local drop-in clinique stating: “TBE-vaccinate yourself against the uninvited guests of the summer. Drop-in, open also evenings and weekends”. Complete with a token-BAME person.

For those of you who don’t live in Stockholm, here are examples from a few infomercial sites:

From https://www.fasting.nu (Pfizer): “One tick bite can be enough — a vaccine exists.”

From https://tbe.se (Healthcare Media): “Lethal tick disease more common than previously known” and “2017: More cases than ever before”.

Plus plenty of pictures of ticks and kids. I’m reminded by the scene in The Truman Show where Truman visits a travel agency to buy a plane ticket and there is a poster of a plane being hit by lightning on the wall behind the sales agent.

Into the sales funnel

Ticks are common also in Denmark and Skåne where I lived before, and while I was taught from childhood to check for ticks and too look out for infection, the danger was Borelia, another tick-borne disease, for which there is a cure (antibiotics, if given early). However, in certain areas, ticks also carry TBE, and one of these areas is the Stockholm region.

So as a good parent, I was naturally fully intended on getting the family vaccinated. Who wouldn’t want their kids to go play in a forest? Which parent doesn’t do their best to protect their kids against the dangers of the world?

First summer in Stockholm came and went without us getting vaccinated (or infected), we were busy doing other things. When life started to calm down — and triggered by the ever present reminders all around — I looked into the practicalities of how to get it done. But there was one thing that was nagging me: Sweden generally provides good public health care, at least for kids, with vaccine programs and regular health checks. So if TBE is so dangerous, why doesn’t Sweden provide the vaccine for free?

So I looked into the facts.

What is the risk of catching TBE?

According to the Swedish health authorities, the number of TBE cases reported per year in the Stockholm region are: 

2017: 146 or 6,32 per 100 000 inhabitants

2018: 116 or 4,94 per 100 000 inhabitants

2019: 98 or 4,12 per 100 000 inhabitants

The numbers I have cited are the cases reported as infected in Sweden. The region of Stockholm contains about 2.3 million people.

For comparison, the number of people who have tested positive with Covid-19 in the Stockholm region so far is above 15 000. However, the vaccine has been around for some time now and I don’t know how many in the Stockholm region has been vaccinated. Maybe we are the last four in the region who hasn’t got our shots?

Checking other sources, here is from CDC: “The overall risk of acquiring TBE for an unvaccinated visitor to a highly endemic area during the TBE virus transmission season has been estimated at 1 case per 10,000 person-months of exposure.”

Also, even if you happen to catch TBE, most cases are mild. Again from CDC: “The European subtype is associated with milder disease, a case-fatality ratio of <2%, and neurologic sequelae in up to 30% of patients. “

Say we are exposed to ticks for one month per year through our behaviour, this puts the odds of someone in the family catching TBE at less than once per 10 000 summers of outdoor activity.

What does the vaccine do?

Vaccines are not miracles, even if they come close. To be fully effective, three doses must be given over one year, with a re-vaccination every 3-5 years. 

From the Swedish Health Authority“After three doses according to the normal time table, almost 100% of the vaccinated is protected for at least three years”

Not bad. Each dose cost around 400 SEK. So the family could be protected for three years for just under 5 000 SEK.

Why doesn’t Sweden provide a free vaccine?

Åland (between Sweden and Finland) provides a free vaccine to its citizens while Sweden has chosen not to do so. In my search to understand why, I found a study by the Swedish Health Authority from December 2018 which clearly examines the costs and benefits for three different vaccine programs.

Essentially doing the same calculations as above, the study concludes that it is not cost effective to provide publicly sponsored vaccination. 

The cost of saving one life-year lands at way above 1 000 000 SEK per year in all of the scenarios. While the study does not put an exact break-even number — as this is essentially a political question — it does state that costs of more than 1 000 000 SEK/year is generally perceived as not cost effective.

This leaves the market open for the commercial actors to convince people like me that what they offer is of value to me. Looking at the dropping number of reported TBE cases for 2019, it looks like they have been very succesful doing this. Or maybe the ticks just didn’t like the hot and dry summers of 2018 and 2019.

My conclusion

My personal risk appetite is definitely higher than 1 per 10 000. So I decided to not get us vaccinated but rely on the well known prevention measures: Wear long trousers and closed footwear when going into the forest, check for ticks when returning home, pay attention also to worn clothes. That saves the family three trips to a clinique and cash for a new iPad. It’s not like we are camping in the archipelago every weekend anyway.

Now after looking into the details, I can safely walk past the infomercials and still feel like a good parent. Of course, if it so happens that one of my kids gets bitten by a tick that causes a serious case of TBE, I will have to live with the consequence of knowing that I — maybe — could have prevented it. Or, hang on, maybe I should buy the kids an insurance, another heavily-marketed product in Sweden…?

Fear sells.