What happens in Spain’s hospitals in the next few weeks will determine whether or not the current rise in coronavirus cases in the country is just an uptick of little consequence, or if it is a sixth wave that will affect the healthcare system. As was reported earlier this week by EL PAÍS, the Spanish Health Ministry and the regions are designing a new traffic light system to assess the risk of the pandemic in a territory. Under this system, more weight is given to indicators that measure the incidence of serious and very serious coronavirus cases, rather than just the basic number of infections. The question now is, will a rise in contagions put more pressure on Spain’s hospitals? And will Covid-19 vaccines continue to protect the vaccinated against serious illness from Covid-19? The data published so far does indicate that hospital admissions have risen slightly, but there is no sign yet that vaccines have become less effective at protecting from serious illness.
According to the latest figures, released Wednesday by the Spanish Health Ministry, there are currently 2,260 Covid-19 patients in hospital, up from 2,164 on Tuesday. This equates to an occupancy rate of 1.82%. The number of admissions for Covid-19 in intensive care units (ICUs) also rose from 427 on Tuesday to 447, with the occupancy rate increasing from 4.68% to 4.90%. Under the proposed traffic light system, a situation is considered under control if the occupancy rate for regular and ICU beds is below 2% and 5%, respectively. The Health Ministry on Wednesday also reported 6,667 new coronavirus cases and added 30 deaths to the official toll, which now stands at 87,775. Meanwhile, the 14-day incidence rate continues to rise. On Wednesday, it came in at 96 cases per 100,000, a 7.4-point increase from Tuesday.
The Health Ministry does not release data on the vaccination status of new coronavirus cases nor the percentage of Covid-19 patients in ICUs who are fully vaccinated. But according to the statistics provided to EL PAÍS by the regions, which are in charge of their healthcare systems, the Covid-19 vaccination drive and coronavirus restrictions in their territory, more than 60% of the 447 Covid-19 patients in ICUs on Tuesday were not vaccinated. In a population where nearly 90% of the over-12s have been fully immunized since the end of September (no Covid-19 vaccine has been approved for children yet), this figure reveals the enormous protection offered by the shots.
To illustrate this point, Salvador Peiró, a doctor of preventive medicine and public health, highlights data from the Valencia region, which are nearly comparable (in proportion) to those of all of Spain. “In the weeks between October 18 and November 14, there were 31 new ICU admissions: 21 who were not vaccinated [the equivalent of 4.5 per 100,000] and 10 who were fully vaccinated [0.24 per 100,000]. ICU admissions of the unvaccinated are 18.7 times greater.”
I definitely think we are in a wave, but it is practically imperceptible because the breeding ground is much smallerRafael M. Ortí Lucas, president of the Spanish Society of Preventive Medicine, Public Health and Hygiene
These figures coincide with the latest studies on vaccine effectiveness from Spain and other countries that show that full vaccination protects against 90% of serious illnesses and deaths. This rate is a little higher or lower depending on the Covid-19 vaccine, i.e. if it is Pfizer-BioNTech, Oxford-AstraZeneca, Moderna or Janssen. The vaccines, however, have become less effective at preventing coronavirus contagions. While studies from the Phase 3 clinical trials carried out a year ago reported that the vaccines were 95% effective at stopping infections, this figure has now fallen to between 35% and 50% due to the emergence of new variants and the fact that some time has passed since the shots were administered.
The spike in coronavirus cases in Spain began to be reflected in the 14-day incidence rate on October 13. A week and a half later, hospitalizations began to rise and on November 6, ICU admissions also started climbing – but only slightly.
“It’s inevitable that a rise in cases will lead to an increase in the number of people admitted to hospital, despite the vaccination drive,” said Rafael M. Ortí Lucas, the president of the Spanish Society of Preventive Medicine, Public Health and Hygiene (Sempshp). “There is a small portion of people who do not generate an immune response [from the vaccine], and others who are vulnerable because technically they are not immunized despite the vaccine. They are not 100% effective,” he said.
When asked if Spain is seeing a sixth wave, Lucas replied: “I look at the sea a lot and I know how to differentiate between waves from storms and those from little breezes. I definitely think we are in one, but it is practically imperceptible because the breeding ground is much smaller. I continue to be optimistic because things were done well.”
Alejandro H. Rodríguez, from the Spanish Society of Intensivist, Critical and Coronary Unit Medicine (Semicyuc), says it is very rare for completely healthy and fully vaccinated people to end up in the ICU. “Generally, they are not vaccinated. Of the three we have now in Joan XXIII Hospital in Tarragona, two – between 40 and 60 years of age – said that they didn’t get immunized because they were very athletic,” he said. According to Rodríguez, the Covid-19 patients in ICUs who have been vaccinated tend to have weakened immune systems or other comorbidities.
However, both experts agree that it is difficult to determine the typical profile of a Covid-19 patient, given that there are very few patients in these units. Indeed in many ICUs, there are none: the average Spanish province has fewer than 10 people in intensive care.
The data that is available on Covid-19 patients in ICUs comes from the Carlos III Health Institute’s records on the fifth wave, which began in June. These figures show that most of these patients were in the 40-70 age bracket. Admissions started to fall for patients over the age of 70, partly because they develop very serious illnesses and are often too fragile to be taken to the ICU. There were also few ICU admissions among the under-40 population, even though the fifth wave spread mostly among youngsters. This is because the elderly are the worst-affected by the virus, while someone under the age of 40 only has a remote chance of being admitted into the ICU.
Hospital figures and diagnosis
In Spain, it is impossible to know how many people diagnosed with Covid-19 had already been vaccinated. Healthcare sources say that out of more than three million diagnosed cases in the first 10 months of the year, 300,000 had been fully immunized. But this is a very tricky data point because in the first months of the year, Spain’s immunization drive was still underway and the percentage of the vaccinated population was very low.
Unlike other countries such as Italy, Denmark, Switzerland or the United Kingdom, which break down figures on Covid-19 patients by vaccination status, the Spanish Health Ministry does not publish this information. Nor did it reply to repeated requests by this newspaper to provide the figures.
At the regional level, Catalonia and Madrid do offer these numbers. Since late June, only 20% and 28% of diagnosed cases, respectively, were among vaccinated people.
At hospitals, specific numbers are also unclear outside of the intensive care units. Only nine out of 17 regions offered figures to EL PAÍS, and these show that nearly 60% of Covid-19 patients in regular beds were fully vaccinated. This rate is to be expected because of the large number of vaccinated people in Spain. Peiró illustrated this idea using data from the Valencia region between October 18 and November 14, when there were 136 new non-ICU admissions: 60 were unvaccinated (12.8 per 100,000 unvaccinated people) and 76 vaccinated (1.9 per 100,000 vaccinated people). “That is 6.7 times more new hospital admissions among the unvaccinated,” he noted.
In Catalonia, for example, health department data show that unvaccinated people are three times more likely to end up in the hospital. But age contributes significantly to the risk factor for the unvaccinated population: those between 30 and 59 years of age, who are generally healthier, are 10 to 20 times at greater risk of ending up in the hospital than their vaccinated peers, according to data published in the last two and a half months. For people over 70, who have more pre-existing conditions, the difference is much smaller: there are two to three times fewer hospital admissions (in relative terms) among the vaccinated.
In any case, Peiró says that the hospital figures should be used cautiously and that vaccinated people are probably overrepresented, as anyone who is admitted gets a PCR test regardless of the reasons that took them to the hospital in the first place. “We’re trying to refine the statistics, but it is very likely that anyone who tests positive is being added to the hospital’s Covid database regardless of whether their condition has anything to do with that.”
This expert adds that sometimes, elderly people living in senior homes are taken to the hospital when they test positive, not so much because they are in a serious condition as to isolate them from other care home residents. And it is not possible to know how much this practice is affecting the data.
As for the coming weeks, experts seem to feel that the recent rise in cases will keep up, but that the impact on hospitals will be relatively small thanks to widespread vaccination.
Spain greenlights booster shots for health staff and 60-69 population
Spanish Prime Minister Pedro Sánchez announced on Wednesday that all health staff and people aged between 60 and 69 will receive a third dose of a Covid-19 vaccine. The decision, which was recommended by the expert vaccination team advising the government, follows growing evidence that antibody levels among the vaccinated drop as time passes. This means that the vaccinated are more likely to contract the coronavirus, even if it is only a minor case. The proposal will now be presented to Spain’s Public Health Committee, which is made up of central and regional health authorities.
On October 5, this committee gave the green light for booster shots to be administered to the over-70 population and care home residents, a group which represents close to seven million people. Three weeks later, it made the same decision for the two million recipients of the single-shot Janssen vaccine. Now, the 5.2 million people aged between 60 and 69, and the 1.7 million health workers in Spain will also receive a booster shot. This means that in total, a third dose has been recommended for 16 million people, which is just over one-third of the population in Spain. The Pfizer and Moderna Covid-19 vaccine are being used for all of the booster shots.