Why is Spain being hit again by the coronavirus pandemic?

The coronavirus pandemic caught Spain unawares back in March, with insufficient personal protective equipment in hospitals and a lack of resources in senior residences. But now, five months later, the country is the European Union state with the worst figures in what already can be classed as a second wave. According to the European Center for Disease Protection and Control, the cumulative incidence of the virus over the last 14 days is now at 152 cases per 100,000 inhabitants, ahead of Malta (119), Romania (88) and France (54).

A month ago, the positive cases being detected in Spain were mostly among young people, and they were asymptomatic. But the spread of the virus has seen a recent rise in hospitalizations and deaths. The concern among health chiefs has risen greatly. “Fernando Simón [the director of the Health Ministry’s Coordination Center for Health Alerts] made it clear,” explained an attendee at a meeting of regional health chiefs last week. “The ministry did not think that we would see these rates of infection until the fall.”

EL PAÍS has spoken to several experts from a number of different areas to explore the reasons for this new spike and the possible ways out of this predicament. The answers range from poor management of the deescalation process and the lack of contact tracers, to the lack of compliance with prevention measures on the part of citizens.

If a new lockdown is to be avoided, they add, the management of the data needs to be improved, and there needs to be quicker intervention in any outbreaks, faster diagnostic tests and more contact tracing. This formula has been cited over and over again in recent months, but the country’s administrations have not been able to implement it.

These are the three questions that EL PAÍS put to the experts:

1. What situation do you consider Spain to be in right now with relation to the coronavirus?
2. Why is Spain the European country with the highest incidence rate?
3. What needs to be done now before the reopening of schools and the start of the fall?

“There is a lack of strategic capacity to manage the pandemic”

Miguel Hernán, an epidemiology professor at Harvard University

1. The situation is deplorable, but the lack of strategic capacity to manage the pandemic is even more worrying. The swift deescalation in May and June was only justifiable if it was accompanied by those strategies. It’s not surprising that there are more cases with the rise in mobility and tourism, but it is surprising that many areas still lack adequate isolation systems for cases and contact tracing, and that it is unknown whether the diagnostic capability will be adequate for the fall and winter. A fundamental problem is that the new outbreak will threaten the health system once more and could cause a slowdown of economic activity. There are no shortcuts that will work: the economy and public health go hand in hand. There will be no economic growth without effective management of the epidemic.

2. The current situation is partly explained by the improvised management and partly by cultural reasons. Epidemics are like fires: they can break out again due to a spark, but not all sparks cause a fire. The number of sparks in Spain is probably higher due to the spontaneity and the closeness of our personal relationships. But anyone who chooses to return to pre-pandemic behavior should commit to not living with older people.

3. We have time to avoid a new lockdown and the closure of schools if we undertake coordinated management of the epidemic, to harmonize decisions. This will not be possible while most of the technical supervision falls to a small group in the Health Ministry that is considered to be consistently overwhelmed.

“We wanted to get back to normality too quickly”

Magda Campins, the head of preventive medicine at the Vall d’Hebron hospital in Barcelona

1. The situation is worrying due to the marked rise in the incidence in recent weeks. The spread is faster and faster and the capacity to contain it is insufficient.

2. The deescalation was probably done too quickly, moving from one phase to another without leaving sufficient time. A second reason was that with the first outbreaks, the capacity to contact trace was not sufficient. Thirdly, in some cases the population has not respected the prevention measures. We wanted to return to normality too quickly. And finally, we haven’t done mass testing until now.

3. We need to increase the tracing capacity. We also have to do mass testing where the incidence has shot up. And finally, and no less important, we have to influence young people, so that they respect prevention measures in order to avoid the transmission of the virus to the older, more vulnerable population.

“Some of the cases are due to the relaxation of individual protection measures”

Antoni Trilla, head of preventive medicine at the Clínic Hospital in Barcelona

1. We find ourselves in an uncertain situation. More outbreaks are being detected and cases and hospitalizations are rising. The epidemic is traveling at different speeds and with different impacts throughout the country, but the situation in Madrid, Aragón and the Basque Country is the most worrying today. There is no sustained nor generalized community transmission, which is why we have to insist on strengthening the strategy of containment and attack: the detection of cases, rapid study of contacts, isolation and effective quarantine, as well as strictly complying with protection measures.

2. There are a number of EU countries (Spain, France, the United Kingdom, Germany…) where cases are rising, most of them mild or asymptomatic. The capacity of carrying out PCR tests has also increased, although we have to improve this aspect. At the end of July, Spain carried out 582 PCR tests per 100,000 inhabitants. France and Germany 680 and the United Kingdom 1,378. It’s likely that a large part of this rise in cases is due to a relaxation of personal protection measures. A number of outbreaks registered point to activities outside (parties, outdoor drinking sessions…) and inside (nightclubs and bars) where distancing is not being observed, people are talking loudly and alcohol is consumed, all of which are risk factors for infection. Twenty percent of cases are under the age of 20.

3. We need to make an effort to begin the school year in the best epidemiological conditions possible. That means few cases and that they are under control. If this is not the case, the situation will be more complicated. The risk of contagion will never be zero, not for children, families, teachers… But we have to accept this and minimize it. Individual protection measures, the reduction of the number of students per class, the ventilation of the classrooms and other measures can be implemented with good will, patience, understanding and solidarity. The administration should make a great effort to guarantee the best safety conditions.

“We could enter generalized community transmission”

Rafael Cantón, chief of the microbiology service at the Ramón y Cajal hospital in Madrid

1. The cases and sources of infection indicate that, if the numbers don’t come down, we could enter generalized community transmission. The high number of PCR tests, compared to the start of the pandemic, makes a better snapshot of the situation possible. The detection of cases and asymptomatic contacts contributes to reducing transmission if the actions are efficient and the population being studied collaborates.

2. The explanation can only be down to a number of factors and includes aspects such as the accelerated deescalation, greater socialization than in other countries, family members living together, nightlife and in some cases, a failure to declare symptoms among vulnerable sectors of society due to a fear of losing employment. Part of the population has relaxed distancing measures, losing their respect for the virus and its consequences for health.

3. Establishing obligatory protocols that reinforce prevention measures, as well as procedures when faced with possible cases. These protocols should also extend to the social and family environments. It’s important that young people, who are contributing in a large way to the rise in transmission, be aware of their importance.

“We are lagging way behind with the adaptation of schools”

Jesús Rodríguez Baño, head of infectious diseases at the Virgen de la Macarena Hospital, Seville

1. The situation is worrying, very worrying in some areas. Hospital admissions are rising and mild cases with no epidemiological relationship with other positives are growing, which indicates that a large part of the transmission in the community is uncontrolled. We can expect that this will soon translate into transmission to more vulnerable people.

2. The virus is the same in all countries, so the hypothesis to consider would be whether the measures taken have been adequate (which measures, when to take them, how to apply them…), if we have lacked resources and whether they have been adequately complied with. These options are not exclusive. It will be important to do a comparative analysis, because currently we are more in an environment of opinion rather than data. The initiative of some colleagues to carry out an independent analysis is absolutely essential.

3. We need to make face-to-face teaching compatible so as not to increase the risks. There is some published data that suggests that the reopening of schools, in some conditions, will not be a problem. But for this data to be applied to our country there are two problems: it’s unclear that these conditions can be observed in all our education centers, and we have higher community transmission than is desirable. And I believe that there have been major errors made both in the technical area (which measures to take) as well as in terms of management (how they are applied and with what funding). There should have been a plan with three levels (complete face-to-face teaching, partial face-to-face and remote) with concrete measures that were clearly specified, so that they could be applied according to the epidemiological situation, and there should have been work carried out over the summer to see the possibilities of adapting the schools and solving the logistical problems. We are lagging behind.

“The start of activity in schools is essential”

Juan Armengol, president of the Spanish Society of Emergency Medicine (Semes)

1. Spain is in a phase of the pandemic where it has areas with outbreaks and areas with community transmission. The latter leads to cases arriving at the emergency room, calls to the 112 emergency line, hospitalizations and intensive care admissions. There is community transmission, although the average rate of [coronavirus] admissions is around 4% of the total. The rise in the absolute number of cases will increase the cases in the emergency room, admissions and deaths. It will be important to reduce the rate of positive PCR tests until it is below 5%.

2. The analysis of the outbreaks is categorical. Most are associated with what is closest to us: family, friends, leisure… Also to the workplace and special situations such as seasonal workers. And there is a low percentage, albeit constant, of outbreaks in residences. All of us could be carrying the virus and situations such as carers, parties, hugs, expressions of friendship, outdoor drinking… can all become excellent mechanisms for transmission.

3. The start of the school year is essential, especially for the most vulnerable sectors. Online learning is very restricted for many layers of society, which will end up doubly disadvantaged. We need to reduce the infection rate as much as possible and increase the groups of the population that will receive flu shots.

“Another lockdown is economically unsustainable”

Ricard Ferrer, president of the Spanish Society of Intensive and Critical Medicine, and Coronary Units (Semicyuc)

1. The situation is very worrying. There are hundreds of patients in intensive care units [ICUs], and in some areas the health system is already under strain. The ICUs are making a huge effort to be able to attend to all patients, whether they have Covid-19 or other pathologies.

2. The Spanish population has been responsible, as was seen during the weeks of lockdown. However, a number of problems have come up that explain the current situation. In some areas, at the time of the deescalation there was still sufficient virus circulating to cause new outbreaks. This is exacerbated by the fact that Spain is a country of services and there is significant movement, especially during the summer. Some outbreaks are related to social problems that need to be solved. Finally, we are culturally very close as a people and this has caused problems among adolescents who have spent months locked down.

3. We cannot allow the current epidemiological situation to continue. It’s not possible to go back to dedicating the hospitals just to the coronavirus and delaying other procedures. In economic terms, another lockdown – which is the only intervention that has really worked – is unsustainable. There is no other option than to clearly identify specific chains of infection and to cut them out at the root. We need to monitor areas with the highest transmission rates with mass PCR testing and confine them if necessary.

“The lack of transparent, quality data is a serious problem”

Pedro Alonso, public health professor at Barcelona University and the director of the malaria program at the World Health Organization

1. We have a serious problem with the quality of the data, but all of it points to the fact that transmission has been growing for weeks now, and with it, hospitalizations and deaths. As is common with infectious diseases, not all regions and communities are being affected equally. Finally, it is notable that European countries with structures and behaviors similar to those in Spain are managing to effectively control transmission. This and the large excess of cases and deaths in the first wave require a deep and multidisciplinary analysis to learn from the mistakes that were made.

2. As 20 Spanish scientists pointed out in a letter to the medical journal The Lancet, in which they called for an urgent and independent evaluation of the response to the epidemic, there are a number of factors that could have contributed to Spain being among the most-affected countries. The list is not exhaustive, but it does include elements related to the public health structures, including the management of emergencies, legal frameworks and coordination mechanisms with the regions, capacities and scientific consultancy, mobility, inequalities, communication and lack of preparedness. Perhaps one of the most serious factors is the lack of transparent, quality data.

3. The country is facing an enormous challenge. No one is sure about what the optimum strategy or approach is. We are arriving in the month of September in worse circumstances than in June. We need to call together the best specialists in transparent technical committees and public consultants. We need to generate consensus in terms of the approaches that should be followed. Consensus and solidarity is needed.

“We need to think about more solid policies for work-life balance”

Joaquín Estévez, president of the Spanish Society for Health Directors

1. Community transmission is currently intense, which has prompted hospitals in some regions to suspend their usual surgeries. For now, it appears that patients have less serious symptoms, but it is fundamental that the system be prepared for a new wave.

2. It’s very worrying and we cannot determine the causes without rigorous analysis of the problems over time. But the causes are rooted in the fact that a sector of society has ignored the fact that no longer being locked down does not mean that the problem has gone away. Political parties should take the situation seriously and work in the same direction, with efficient coordination between the Health Ministry and the regions.

3. The reopening of schools means, at least, two essential issues. On the one hand, safety, and on the other, its impact on the work-life balance of families, with the social and economic implications that has. Protocols set out by the central government that guarantee the safety needed for there not to be infections in schools are fundamental, and the regions need to turn these protocols into plans and specific measures adapted to their concrete situations. More solid work-life balance measures need to be thought out, which will allow families to carry out their jobs and, at the same time, attend to their children, taking into account that in many cases face-to-face classes will be combined with virtual classes.

English version by Simon Hunter.