If Madrid were a house and the coronavirus were the fire, the entire region would be in flames right now. Javier del Águila, a specialist in preventive medicine and public health, uses this simile to illustrate that the contagion levels being discussed by politicians as the threshold to introduce mobility restrictions “is like discussing whether to act when the fire has already reached the foundations of the building, or a little earlier.”
“It is already late,” he adds.
The Spanish Health Ministry and the Madrid region have agreed to introduce restrictions in areas with a population of 100,000 and over with a 14-day cumulative incidence of 500 cases for every 100,000 people, where 10% of tests are coming back positive, and where more than 35% of intensive care beds are taken up by Covid-19 patients.
But these thresholds are far looser than those recommended by relevant international organizations. The Harvard Global Health Institute says that stay-at-home orders should be issued when the incidence rate reaches 350 cases per 100,000 people. Madrid has a figure twice as high, but is not contemplating any form of home confinement.
Meanwhile, Germany has agreed to take measures in areas with a cumulative incidence rate of 100 cases per 100,000, the same metric used by Belgium to activate its most restrictive scenario. And Britain has been introducing confinements with a rate of 225 cases per 100,000. In France, the toughest measures are rolled out when the rate reaches 150 cases per 100,000.
Experts agree, however, that the incidence rate by itself is not enough to warrant measures. The two other indicators adopted by the central and Madrid governments contribute to a more complete picture, they say.
But again, the limits are too loose. The World Health Organization (WHO) notes that when over 5% of PCR tests come back positive, this can be considered to reflect community transmission. Yet in Spain, the positivity rate at which restrictions are required has been set at 10%. Right now the national average is 11.2% according to the latest report by the Spanish Health Ministry. In Madrid, over 20% of PCR tests are coming back positive.
Daniel López Acuña, a former WHO official, welcomes the adoption of specific limits in Spain, something that he and other colleagues had been requesting since April. But he says that three metrics are not enough. and that the primary care system’s ability to deal with Covid-19 cases should be considered as well. To these variables, Del Águila adds contact tracing capacity.
Too late for Madrid
The problem, according to a dozen specialists consulted for this story, is that it’s already late for Madrid. The region this week adopted new protocols to do PCR tests only on the closest contacts of positive cases and on vulnerable individuals.
“This is tantamount to admitting that the epidemic is out of control and that there’s been a failure. And it happened because they allowed it to happen,” says Del Águila.
Although there is no such thing as a scientifically indisputable metric to know exactly when to adopt looser or stricter restrictions, the problem with waiting until a location has the kind of contagion levels seen in Madrid is that, at that point, it is no longer possible to keep transmission in check.
Now that new restrictions are about to go into place, the big question is whether they will be enough to make a significant difference. The figures will be reviewed every week in order to adapt the response, but many experts are already asking for stricter, and above all different, types of measures.
“We’re running late for mild measures such as reducing capacity at bars and restaurants,” notes Del Águila. “On one hand you’re allowing indoor dining, which is where the greatest risks lie, and on the other you’re shutting down children’s playgrounds, which are a lot safer. Maybe that would have made sense a month ago, when it could be controlled, but right now we are in a situation where you need to ask or force people to stay home.”
With reporting by Rafa de Miguel, Lluís Pellicer, Ana Carbajosa and Silvia Ayuso.
English version by Susana Urra.