Coronavirus cases falling in Spain, but hospitals remain under pressure

The epidemiological curve of the coronavirus is finally starting to fall in Spain after two weeks stuck in a plateau. According to the latest report from the Health Ministry, which was released on Thursday evening, the 14-day cumulative number of coronavirus cases per 100,000 inhabitants has fallen below 202 for the first time in a month. But the risk level is still high under the criteria established by the central government.

While the trend is positive, the uneven control of the pandemic from region to region and the ongoing high pressure on the healthcare system are prompting the experts to remain on alert. There are six Spanish territories in the government’s extreme risk scenario, with a 14-day cumulative number of cases above 250 per 100,000 inhabitants. Meanwhile, one in five intensive care unit (ICU) beds is occupied by a Covid-19 patient.

According to Thursday’s report, there were 7,960 new coronavirus infections detected and 160 Covid-19 fatalities were added to the official death toll. In total, 3,559,222 people have been confirmed to have had the coronavirus in Spain since the pandemic began, while 78,726 people have died after testing positive for the virus.

To compound the precarious situation, the state of alarm that was put in place six months ago to give the country’s regions the legal framework needed to limit fundamental rights such as mobility is due to expire on Sunday. This will mean that restrictions aimed at controlling the spread of the virus, such as nighttime curfews and perimetral lockdowns, will only be possible if they are backed by the country’s courts. The epidemiologists consulted by EL PAÍS warn that “the pandemic is not over,” and if the restrictions are slackened, there could be dangerous spikes.

There are some regions with major problems and we cannot downplay high incidences just because they are among younger people

Daniel López-Acuña, former WHO official

“The epidemic is progressing well, but we still have a lot of fatalities and cases in the ICU,” Fernando Simón, the director of the Health Ministry’s Coordination Center for Health Alerts (CCAES), explained at a press conference on Thursday. “We continue to have very high hospital occupation.”

The visible face of the government during the health crisis went on to express his optimism, however, and said that while “an increase in mobility that is associated with a rise in transmission cannot be ruled out,” he thought it to be unlikely.

Simón rejected the possibility of implementing homogenous rules across the country from May 9 onward, when the state of alarm ends, and called instead for the risks to be evaluated from region to region and action to be taken according to specific epidemiological situations. “I would not consider equal measures for everyone,” he said.

In Spain the vaccination campaign is moving along at a satisfactory speed, with 12% of the population having received the full protection offered by the vaccines being used. The more vulnerable sections of society are protected against the most serious effects of Covid-19 as well as the risk of death – 81% of the over-60s, for example, have received at least one dose of a vaccine. But at the same time, community transmission is high in the vast majority of the country’s 17 regions, and there continues to be high pressure on ICUs. There are only six territories – the Canary and Balearic islands, Valencia, Galicia, Extremadura and Murcia – that are below 100 cases per 100,000 inhabitants over a 14-day period. In the Basque Country the incidence is as high as 478.

“It is evident that we are not faced with a uniform situation,” said Daniel López-Acuña, a former director of emergencies at the World Health Organization (WHO). “There are some regions with major problems and we cannot downplay high incidences just because they are among younger people. There may be a lower level of mortality, but there is still a problem with the severity [of the illness] and the occupation of ICUs.”

In fact, while the average incidence in Spain has fallen, the occupation of Covid-19 patients in ICUs refuses to fall, and has for weeks now been hovering around the 20% level. That said, Simón insisted last night that the peak of hospital occupation has now passed and is starting to fall.

Alberto Infante, emeritus professor of international health at the Carlos III Health Institute’s National Health School, pointed out that people with more serious symptoms spend more days in hospital. “The treatments that we are applying help a number of older people – that’s to say, the fatality rate has fallen,” he explained. “But they come out alive thanks to [being in hospital] for more time. As such, although there are fewer admissions because the vulnerable population is already protected, patients are staying in the ICU for more time. There is less rotation of beds and the occupation is not falling,” he added.

According to the latest data from the Health Ministry, 2,212 people are hospitalized in the ICU due to Covid-19. Across the country, 22% of ICU beds are occupied by coronavirus patients, with the figure as high as 42% in regions such as Madrid. The number is in excess of 35% in Catalonia, Ceuta, the Basque Country and La Rioja. “This means that there is a high percentage of ICU beds that are not being used for other pathologies,” said Infante. “And we could pay for that in the future in terms of excess deaths due to other causes because we haven’t avoided admissions due to Covid.”

Key moment

Spain is experiencing this fall in incidence at a key moment in terms of controlling the pandemic. Without the state of alarm, the regions will have to rely on the blessing of the courts to keep restrictions in place, and epidemiologists fear that the time that these legal processes will take could interfere with attempts to keep the pandemic under control.

“We cannot under any circumstance lift the restrictions from one day to the next in those regions that are above 250 cases per 100,000 inhabitants, and that have intense levels of community transmission,” warned López-Acuña. “When the legal coverage disappears, there will be a risk that we will have spikes from the end of the state of alarm because there will be more mobility and interaction.” The experts also warn that the more the virus circulates, the greater the risk of new variants.

Spain’s regions have started to make moves to keep some restrictions in place, including nighttime curfews and limits on numbers at social meetings. At least seven regions are planning on keeping some of the existing measures in place, but for now only the Balearic Islands has secured backing from its high court to keep the curfew in place and limit meetings to six people beyond Sunday.

“My fear is that from May 9 onward, we will understand the precautions to have been lifted along with the end of the start of alarm,” added Infante. “It is important to make an effort to explain to citizens that the pandemic is not over.”

Epidemiologist Salvador Peiró, from a healthcare and biomedicine research foundation in Valencia, agreed that there is the “threat of a spike” associated with “the reduction of restrictions, less social support for the measures, optimism and the loss of fear of meeting with vaccinated seniors.” He added, however, that it is “fairly unlikely” that there will be outbreaks with the same mortality levels as in other waves.

At a meeting this week of the Inter-Territorial Council of the National Health System (CISNS), which brings together the central Health Ministry and regional healthcare chiefs, the latter called for common guidelines to deal with the pandemic once the state of alarm is over, given that they fear a repeat of the judicial chaos seen last summer when there were a series of contradictory rulings across the country or even within the same region.

The central government, meanwhile, has been arguing that the existing legal framework is sufficient to keep the pandemic under control, and has offered to review the latest risk-level system approved by the regions as well as the coordinated actions associated with this indicator. The measures will only be recommendations, however, and will not be obligatory for each territory.

Test and trace

The experts are also calling for active testing and tracing of cases and contacts to continue. Peiró believes that Spain is “headed toward a three-pronged approach: vaccinate as much as we can, enforce testing and outbreak control, and adjust policies in order to reduce the infectious episodes among youngsters. We cannot allow outbreaks such as the one in Valencia’s Ausiàs March university residence, with 120 people affected, because if you don’t detect them, they create an uptick among young people and can make other strategies, such as vaccination, much more difficult.”

According to the Health Ministry’s latest report, around 1,850 diagnostic tests are being carried out for every 100,000 inhabitants, and the positivity rate is 6.68% – above the 5% level that the authorities have set to consider transmission of the virus under control. “Contact tracing has fallen off the map from a media and healthcare point of view,” said López-Acuña. “While it is true that fewer tests are being carried out as the incidence falls, we should take advantage of the situation right now to do more testing and seek out infections.”

English version by Simon Hunter.