“The mortality rate is the last thing to rise but then it’s very difficult to get it down”

August is not yet over but already among experts and healthcare managers there is a general conviction that an ominous autumn awaits Spain, where they expect a significant spike in mortality related to the coronavirus. The figures will not reach those of March and April, which allows the optimists to see the glass as half full, but they will be higher than many were forecasting until not so long ago.

“Several weeks ago, cases began to grow significantly,” explains Daniel López Codina, from the computational biology and complex systems research group at the Polytechnic University of Catalonia. “And when that happens, without an effective treatment, the rise in mortality is inevitable.”

Spain saw just a dozen Covid-19-related deaths a week on average during July. The curve even began to fall during the first two weeks, according to data from the Health Ministry, given that the majority were people who had fallen ill during the first wave of the coronavirus and had spent months in the intensive care unit (ICU). The trend changed when August arrived, and in recent days the weekly average has risen to 120 fatalities. This figure is, in reality, even higher given the delays in notifications from the regions to the central Health Ministry, and it is likely that the numbers will continue to grow on a sustained basis.

First the infections go up, then between 10 and 15 days later the hospitalizations rise, and then toward the third week, mortality rises

Francisco Javier Falo, the general director of public health in Aragón

The data offered by the European Center for Disease Prevention and Control – which is based on the information sent by the Health Ministry – show that mortality in Spain has doubled in less than two weeks, going from 0.4 deaths per 100,000 inhabitants to 0.8. The information from the regions confirms this trend.

“Mortality is the last thing that rises,” explains Francisco Javier Falo, the general director of public health in Aragón, the region that has seen the highest infection rates this summer. “First the infections go up, then between 10 and 15 days later the hospitalizations rise, and then toward the third week, mortality rises. It’s the last thing that goes up, but then later it’s very difficult to bring it down, because groups of patients in a very serious condition start to accumulate in hospitals and often they do not progress well.”

In Aragón, cases shot up in the second half of July. At the end of that month, the deaths in the region were 15 a week, a number that was multiplied by five by mid-August, to reach 72. Since then, and despite the notable fall in new infections, the fatality rate is dropping a lot slower. In the last week the number came in at 62.

In Madrid, where the new spike in infections began three weeks ago, the number of fatalities is on the rise. According to the totals offered by a group of professionals from the region’s hospitals, the number of deaths on August 21 were nine; on the 25th they were 13; and on Friday they rose to 22.

Spain emerged from lockdown with the virus still present in just two sectors: healthcare, and areas that continued to operate throughout the confinement period, such as the agriculture sector

The situation is very different to that of March, the experts point out. Then, practically all cases diagnosed were patients in a serious condition. The immense majority of the mild cases – and all of the asymptomatic cases – were not detected, something that caused the fatality rate to shoot up to nearly 20%. Now, while the rate is expected to rise, it is currently relatively low. The reason for this? “The first infections were mostly in circles of young and healthy people, with a more intense social life,” explains Daniel López Acuña, the former director of emergencies at the World Health Organization (WHO). “Although with the passing of the days, in their family and professional lives, they end up transmitting the virus to the elderly or vulnerable people.”

The experts see this as the origin of the problem in Spain. The country emerged from lockdown with the virus still present in just two sectors: healthcare, and areas that continued to operate throughout the confinement period, such as the agriculture sector. In spite of all of the warnings, the coronavirus was still able to jump from these areas to young people first, before spreading via nightlife and family events, and will end up reaching the most vulnerable.

The reasons that explain this situation, according to sources consulted for this article, are a mix of the population dropping their guard in terms of protection measures, the inability of the regional governments to strengthen services to monitor the epidemic, and delays when it comes to adopting measures such as the 11 guidelines agreed by the Health Ministry and the regions two weeks ago, which included the closure of nightlife venues and the protection of senior residences, among others.

Once the virus has regained the lost ground, it’s very difficult to make it retreat. “The only way to significantly reduce mortality now is to reduce infections, in particular among the vulnerable population,” insists Miguel Hernán, an epidemiology professor at Harvard University. “And there is no other way to achieve this but early diagnosis, the tracing of contacts and isolation measures.”

“Gradual and flexible” measures

Jacobo Mendioroz, the head of the virus-monitoring unit at the Catalan government, argues that the experience in Catalonia – which ended up confining several areas, including Lleida – as well as that of Aragón show that what is needed is to “act as soon as possible.” The key, he continues, “is to do so when infections are still happening among younger people, strengthening tracing and isolation, and control measures. This avoids transmission from reaching the vulnerable and the incidence from reaching very high levels. That’s when it becomes very difficult to bring down, particularly in cities.”

These measures, Mendioroz explains, should be “gradual and flexible, surgical,” with the pressure rising or falling according to the epidemiological progress.

Miguel Hernán bemoans the “clearly insufficient efforts that many regions have carried out in terms of epidemiological monitoring. It appears that their leaders believe that an explosion of cases can be avoided by the use of masks because a percentage of the population has already had the infection, and as such has a relative immunity for several months or years. I don’t know if someone has done this calculation, but it’s the only justification that could explain the insufficient focus on monitoring measures.”

English version by Simon Hunter.