The family of 71-year-old Juan Antonio Manrique had put him “in a bubble.” In the midst of the pandemic, this chronic kidney patient required dialysis three times a week, and was considered high risk from the coronavirus. “He was very weak,” explains his daughter Encarnación. “We couldn’t even celebrate his 50th wedding anniversary.” Juan Antonio was forced to get in an ambulance every other day to go for his dialysis, which he received alongside other patients. It was a half-hour journey between Roquetas de Mar (Almería) and the capital of the province, a trip that he also shared with other kidney patients. He ended up catching the virus and died after developing Covid-19, as did the other three patients with whom he traveled in the ambulance. It is not known whether the vehicle was the point of contagion.
Maintaining an isolation bubble has become impossible for a lot of dialysis patients and many have been lost to the pandemic. More than 4,700 kidney patients have caught the coronavirus and the mortality rate has been 25% among this group, according to the Spanish Nephrology Society. In fact, this very high risk of death has prompted the Health Ministry to prioritize such patients in the vaccination campaign.
The Health Ministry has started to specify which collectives it considers to be at greatest risk for the purposes of the campaign, but is still yet to announce how and when they will get their jabs
After the elderly, medical staff and essential workers have received their inoculations, it will be the turn of other vulnerable groups: transplant recipients, cancer patients undergoing chemotherapy, lung cancer patients and people with Down syndrome who are aged over 40. The Health Ministry has started to specify which collectives it considers to be at greatest risk for the purposes of the campaign, but is still yet to announce how and when they will get their jabs. So far the ministry has only specified that the vaccinations will begin when the 80-and-over population has been inoculated, a process that is ongoing, but is yet to announce which vaccine will be used or when the jabs will start.
Many people with a chronic condition or in another at-risk group were hoping to enter this block in the vaccination campaign. The Spanish Society of Preventive Medicine, Public Health and Hygiene includes the following in their collectives considered to be most at risk: the obese, people with cirrhosis, schizophrenia or multiple sclerosis, oncology patients or those with a history of cerebrovascular illness. But with the vaccines still arriving at a slow pace, priority groups needed to be established.
Cristina Avendaño, the coordinator of the vaccination group at the Federation of Spanish Scientific Medical Associations (Facme), the body that has worked with the Health Ministry to prioritize risk groups, explains that they will deliver the ministry with “the report that identifies the risk groups; there are some that are clear and defined, but that’s not to say that they are the only ones. These are conditions that identify patients with a very high risk of serious disease and death associated with Covid. The idea is not to make a precise list, but rather to go by blocks. Right now it is the turn of the block with much more risk.”
Analysis of the scientific evidence has been key to settling which are the most serious conditions and the criteria that has taken precedence is the risk of mortality associated with Covid, insist those who have contributed to the decision making. “I understand that people are anxious because their illness creates a sensation of vulnerability to the virus,” says Federico de Montalvo, the president of the Spanish Bioethics Committee and a member of the board that decides on Spain’s vaccination strategy. “But the feeling of risk is one thing and scientific evidence another. There are situations where the illness is fatal and others where it is not.”
What has also had an influence is the fact that these groups will have to overlap with the vaccination of people aged 70 and over, Avendaño admits. “We have to take into account the availability of the vaccines and the workability,” he says. “For dialysis patients, for example, the risk of serious illness is combined with the fact that they go to hospital, which is a different circuit from primary healthcare, and allows for them to overlap with the vaccination of the over 70s.”
The experts consulted for this article agree that the groups that have been selected by the Health Ministry are adequate. Here are the priority groups so far:
Dialysis patients. The risk of mortality for this group from Covid-19 is 3.5 times greater than the general population in the same age group and sex, according to Facme. “These patients are already in a state of immunosuppression and usually have a lot of pathologies. Coming to the hospital for dialysis is a risk because they also usually come in collective ambulances, something that has meant a higher number of contagions,” explains Patricia de Sequera, the president of the Spanish Nephrology Society. The daughter of Juan Antonio believes that this is what happened in the case of her father and is preparing a lawsuit along with two other families of dialysis patients who died of Covid, Javier Arroyo reports.
Transplant patients or those on a waiting list. This collective has very low defenses due to taking immunosuppressants in order to avoid the body from rejecting the new organ, meaning they are more vulnerable to infections. “They have a mortality risk that is up to six times greater than the general population, albeit there may be differences according to the type of transplant, the time that has passed or the intensity of the immunosuppressive treatment,” Avendaño explains. The Catalonia region has already opted to bring forward the official decision to vaccinate this group, and started to call them for their jabs two weeks ago.
The over-40s with Down syndrome. A number of studies point to this group having considerably higher rates of medical conditions and mortality from Covid-19, in particular from the age of 40. “What we’ve seen is that, as people with Down syndrome age prematurely, their biological age does not match up with their chronological age,” explains Natalia Cuenca, coordinator of the Barcelona Down Medical Center from the Catalan Down Syndrome Foundation. “Genetically they are also more susceptible and they have factors that worsen Covid.”
Oncological patients. The Health Ministry has opted to start with all of those patients with blood cancers and solid tumors who are receiving chemotherapy treatments. Particular focus will be paid to lung cancer patients, whether they are receiving chemotherapy or immunotherapy. The president of the Spanish Medical Oncology Society, Álvaro Rodríguez-Lescure, says that “the prioritization is suitable as far as we are concerned. People with lung cancer have long histories of chronic bronchial disorders and the risk of death and complications and death with Covid is much greater.”
For now, the Health Ministry is not prioritizing any mental health patients in the first group of the chronically ill – not even those with depression or schizophrenia, who have the highest risk of complications and deaths associated with Covid. “They have the same risk as a person with a transplant,” argues Celso Arango, the president of the Spanish Psychiatry Society. “If you have a serious mental health condition you have double the chances of catching Covid. And if you are infected, you have twice the chance of dying.”
The scientific organization has sent a letter to the Health Ministry calling for this collective to be prioritized. Arango argues that the most urgent thing is to vaccinate those with schizophrenia, bipolar disorder and personality disorders. “We know that people with serious mental illness take longer to request help because they have a higher pain threshold and greater difficulty to ask for help given their cognitive situation. They take longer to arrive and they arrive in a worse state,” the psychiatrist warns.
English version by Simon Hunter.