Scaling back confinement in Spain: More critical care beds and improved testing

After six weeks of strict confinement in Spain, deescalation measures have begun: children were allowed out for walks this past Sunday, and if contagion levels keep dropping, the daily outings will be extended to the entire population next weekend.

But in the absence of a vaccine or herd immunity against the coronavirus, Spain’s Health Alert and Emergencies Coordination Center has established a series of conditions that must be met for safe deescalation. The goal is keep new contagions at a level that the healthcare system can cope with.

The central government rejects the idea of regions freely adopting their own pace of deescalation

To this effect, regional health authorities must be prepared to double their number of available critical care beds if there is a new spike in cases. The health system will also need to create centers dedicated exclusively to Covid-19 patients, or at the very least have a separate entrance for them at existing facilities. And primary care centers should have the ability to take samples and send them to laboratories for PCR testing, which identifies people with an active infection, within 48 hours.

On Monday, authorities also began conducting a long-announced nationwide study to determine what percentage of the population has antibodies against the SARS-CoV-2 virus. The study will test 90,000 individuals from 36,000 families three times at three-week intervals.

Declining transmission

The health coordination center on Sunday handed Prime Minister Pedro Sánchez a document with the strategic guidelines for safely ending the confinement, which began on March 14 when the Spanish leader declared a state of alarm.

The number of daily coronavirus deaths officially registered in Spain was 331 on Monday, according to the latest figures provided by the Health Ministry, up from 288 on Sunday but down from a peak of 950 fatalities on April 2.

Regional governments, which have devolved powers over healthcare, also received the new guidelines. On Monday, a meeting of central and regional health authorities is due to establish the indicators that will determine which areas already meet the new conditions for safe deescalation, and which do not.

“Until these [indicators] are defined and a quantitative and qualitative analysis conducted, we cannot know which regions meet the requisites,” said Health Minister Salvador Illa on Sunday.

The document also includes a political message: the central government rejects the idea of regions freely adopting their own pace of deescalation, but it concedes that general measures will be adopted after seeking agreements with regional leaders.

Challenges

Experts consulted by this newspaper supported the document, but noted that there may be a lack of resources to fully implement the measures. Another challenge is knowing when those additional critical care beds will be necessary.

“We probably won’t know when there is going to be a spike,” said Toni Trilla, head of preventive medicine at Clínic hospital in Barcelona. “That is why good epidemiological monitoring is necessary: if it detects 200 mild cases, you can figure that 20% will get complications and end up in the hospital.”

Salvador Tranche, president of the Spanish Society for Family Medicine, said he is skeptical about the idea of creating specific care centers for suspected Covid-19 cases. “Those centers might have been justified at the height of the pandemic, but they don’t seem to me like a good proposal for the immediate future,” he said. “It is almost impossible to clearly differentiate the suspected cases because they’re not just the ones with respiratory issues, but also digestive and neurological ones, and fever.”

The guidelines also recommend creating an alternative entrance for Covid patients at hospitals and health centers. “The separate circuits are more reasonable [than dedicated facilities] but I think it is better to work with the hypothesis that anyone walking through the door could be a Covid-19 patient, and to work with a common prevention [plan],” says Trilla.

Tracing cases

The document also asks primary care centers to make sure they are able to take samples for PCR testing and send them to labs in less than 48 hours. Tranche wants more autonomy on this front. “Even today, if you have a patient with symptoms and you want to do a PCR test, you need to call a number, explain the case, and if they consider it appropriate, they will send someone over to take the sample. This takes several hours,” he explains.

The health emergency coordination center also underscores the need to identify people with symptoms, test them and trace their contacts. This “active search” could be conducted by consulting records of deaths, sick leaves and calls to emergency numbers. The idea is to place positive cases under “supervised isolation and in the right conditions,” which could entail a hotel if the person’s home is not adequate for the quarantine period.

The guidelines also include recommendations for specific protocols for senior residences and care homes, which have proven to be epicenters of the disease. “This item requires further development,” said Pere Godoy, president of the Spanish Epidemiology Society (SEE). “They are centers with a very high risk of mortality and admission into the ICU [intensive care unit], and in this new period it must be a priority to prevent the virus from entering them.”

English version by Susana Urra.