The Covid-19 vaccination campaign got going on Sunday in Spain, in a senior home in Guadalajara, in the region of Castilla-La Mancha. There, Araceli Hidalgo, 96, became the first person in the country to receive the first of the millions of injections that are due to be administered in the coming months. But what happens now? Here are some of the main unknowns – some of which have responses, and others that don’t.
When does the vaccine begin to take effect?
The Pfizer vaccine, which was the one that was symbolically administered on Sunday in all of Spain’s regions, needs two doses, separated by 21 days. Total immunity – at a level of around 95%, according to clinical trials – is reached around a week after the second dose. After that, the immune system begins to activate and it is less likely that the recipient will develop the illness than those people who haven’t been given it, but the drug has yet to achieve its maximum potential.
How long does the immunity last?
This is not known, and is something that happens with all new vaccines: it is unknown how long the immunity lasts until the moment that the vaccine is no longer effective. Laboratories and healthcare services will be monitoring when this takes place. For now, it has not been ruled out that a booster shot will be necessary a year or two after it is first administered, as is the case with other vaccines. In fact, the vaccine could be needed on a yearly basis. But this will only become clear with time.
When and how will Spain’s healthcare centers start to offer appointments for vaccinations?
Sunday saw the start of the first phase of the vaccination plan, which covers residents of senior homes and their carers, and will continue with healthcare workers and adults with major dependencies. This first phase, which will see approximately 2.5 million people given the vaccine, will last around three months. Once it is over, it will be the turn of the next group, although the Spanish government is yet to confirm who this will include. The most likely approach will be the over-64s and the chronically ill. While the plans for this phase are yet to be confirmed, it is expected that these people will be given appointments via their primary healthcare centers. “Citizens will be given a citation, according to the risk group to which they belong, to attend their healthcare center,” explained Health Minister Salvador Illa on Sunday. “It is voluntary and free. It is an act that will benefit both the person who receives the vaccine and the collective.”
Who is considered to be a dependent?
According to the Health Ministry’s vaccination strategy, this group includes people considered major dependents (grade III) according to the Dependency Law of 2006, those who have requested recognition as such and those who are yet to do so but are accredited medically to have an illness that requires intense support measures during their day-to-day lives, whether or not they are institutionalized. “The vaccination will take place as soon as possible, taking into account the characteristics of storage and usage of the available vaccines,” the ministry strategy adds. “Personnel who professionally care for these people with a major dependency will be able to get vaccinated during the same visit.”
What happens for those people with private health insurance?
The vaccination will be free and will be administered by the National Health System in the order that the Health Ministry establishes.
What measures must be followed when the vaccine is received?
In principle, the same as those being observed until now, until there is a sufficient amount of the population vaccinated so that herd immunity is reached. This is estimated to be about 70% of the population. While it is known that the vaccine is highly effective at avoiding the development of Covid-19, it is not yet so clear up to which point it avoids the spread of the virus. This means that it is possible that a person who has been vaccinated could still spread the virus while asymptomatic and thus become a vector for transmission.
When will enough people in Spain be vaccinated in order to achieve herd immunity?
As time passes, more vaccines will arrive – not just from Pfizer, but also, most likely, from other manufacturers too. While the initial rhythm is expected to be around 350,000 injections a week, as more and more pharmaceutical firms get approval for their vaccines this number is likely to rise. The Health Ministry calculates that between May and June around 20 million people will be vaccinated and that by the end of the summer a sufficient percentage of the population will be immunized in order to reach herd immunity.
How will people who have been vaccinated be monitored?
All citizens who receive the vaccine will get a vaccination card that will include the kind of immunization that has been administered as well as the batch number, the date the first dose was delivered and the planned date for the second injection. The card will also contain contact details should there be a suspected adverse reaction as well as a phone number to call should there be any side effects not included in the prospectus. This is the start of what is known as Phase 4 of the clinical trial. In the previous stage the frequent side effects – such as fatigue, tiredness, fever the next day – were found to affect at most one in every 30,000 people. But to detect rarer effects, those that manifest in one case per 100,000 or 1,000,000, the vaccine will be monitored as it is administered in the population. Also, more precise data will be collected on population groups that was not possible during the first trials. This will be done via the primary healthcare system using a centralized database in each region, and will be connected to a national and European system.
Spain’s coronavirus incidence rate falls for the first time this year, but pressure on ICUs rises
The third wave of the coronavirus has pushed Spain to the breaking point. According to the Spanish Health Ministry’s latest report, released on Thursday, the country has started to flatten the curve of new infections, but it has done so at crisis levels, with pressure on hospitals, especially in intensive care units (ICUs), close to unbearable. This pressure continues to rise across almost all of Spain.
The last 10 months of the pandemic have shown that there is not one but various peaks in a wave. The first is the number of new infections. The second is the spike in hospital admissions, which tends to happen a week later, and takes a little longer to be reflected in ICU figures. The final peak, which indicates a change in trend, is the number of deaths. The Health Ministry added 515 fatalities to the official count on Thursday, a terrible toll that is likely to remain at these levels for days to come while Spain transitions from peak to peak.
The latest data indicates that Spain is starting to see the other side of the peak of new infections in the third wave. A week ago, the Health Ministry reported a record-high 44,357 new coronavirus figures. On Thursday, that figure fell to 34,899. It is also the first day this year that the national incidence rate has fallen: the 14-day cumulative number of cases per 100,000 inhabitants now stands at 890, down from 900 on Wednesday.
Hospital admissions fell for the first time this year on Wednesday, with the percentage of Covid-19 patients in hospital wards dropping to 24.10%, down slightly from 24.03% on Tuesday. This data point fell again on Thursday, although the drop was again only marginal. But pressure continues to mount in Spain’s ICUs, which are the last line of defense of the healthcare system. If they are overwhelmed, authorities may be forced to introduce tougher restrictions, such as home confinement. Making matters worse, the pressure on ICUs is rising amid the uncertainty over how the emergence of new, more contagious strains of the coronavirus, such as the B.1.1.7 variant detected in the United Kingdom, will impact the pandemic in Spain.
“According to the data we have, we can expect that it [the B.1.1.7 variant] will be the dominant one in Spain by the end of February or the first fortnight of March. This has some implications because the strain is more transmittable,” said Fernando Simón, the director of the Health Ministry’s Coordination Center for Health Alerts (CCAES), at a government press conference on Thursday. The health official previously said this would not happen until a later date.
Simón admitted that there are small areas in Spain where the new strain already accounts for 20% of cases, but said nationally this figure was “around 8%.” With respect to restrictions, the health official said that “the measures that must be taken” are the same for the new and old variants of the coronavirus. “More measures can still be implemented without modifying the state of alarm,” he said, in reference to the emergency decree that gives regional governments – which are responsible for managing the health crisis – the power to introduce measures such as perimetral lockdowns, but not home confinement.
The figures released on Thursday also do not reflect how the coronavirus situation differs between each of Spain’s 17 regions. Indeed, the fall in hospitalizations over the past two weeks is mainly due to improvements in two regions: Valencia (which, despite this, remains in a “very critical situation,” said Simón) and Catalonia, which reported 466 fewer occupied beds on Thursday than on Tuesday. In Castilla y León, Galicia and Andalusia, there continue to be more hospital admissions than discharges.
“There are 11 regions where the situation is stabilizing or on a downward trend, but this is not the same as a fall in the hospital occupancy rate. The pressure on hospitals will continue over the coming days,” said Simón.
Andalusia and Galicia, as well as Murcia and Valencia, are some of the regions that are being hardest hit by the third wave of the pandemic, with the situation even worse than what it was during the first wave.
The big problem continues to be in ICUs. On Thursday, the Health Ministry reported 97 more ICU admissions than on Wednesday, and no region has managed to clearly reverse the upward trend. In other words, the peak of ICU pressure is still to come. In more than half of Spain, Covid-19 patients occupy more than 40% of all ICU beds – a similar figure to all other diseases combined. In the Balearic Islands, Castilla y León and Extremadura, the occupancy rate is more than 40%; in Castilla-La Mancha, Catalonia, Madrid and La Rioja, it is more than 50%; and in Valencia, it is 63%, a record high not seen since April last year, during the first wave.
As experts warned, the source of the problem is that Spain entered the third wave – which started after the December 6 long weekend – before the second wave was over. This meant that the ICU occupancy rate of Covid-19 patients, which was below 15% in October when the number of new cases began to rise, was already at around 30% in some regions when the third wave hit.
Covid-19 vaccine doses going to waste in some of Spain’s regions due to unsuitable syringes
Spanish regions such as Andalusia, Catalonia and Madrid are wasting thousands of doses of the Pfizer-BioNTech Covid-19 vaccine by not injecting patients with the sixth dose contained in the vials. Since January 8, when the European Medicines Agency granted authorization, the five initial doses contained in the vials are now officially six, increasing the number of potential recipients.
But this change has not been exploited by a number of Spain’s territories, who are in charge of their own vaccination campaigns. Speaking on Thursday in the regional parliament, Andalusia’s health chief Jesús Aguirre admitted that this was the case. “You could take out up to five doses and there was a wee drop left, and that little bit is used to administer that sixth dose,” he said. “But we are talking about 20% more vaccinations.”
The Andalusian regional government has blamed the failure to use this dose on a “deficit of 0.1-millimeter syringes,” the type that is usually used to inject insulin or in pediatrics, and has promised to solve the issue. The extraction of the sixth dose is more difficult with the 0.2-millimeter syringes also being used to administer the vaccines.
Based on the information offered by Spain’s regions, it is impossible to calculate how much of the vaccine has been wasted. Catalonia, for its part, has admitted it is only using the sixth dose from “two-thirds” of the vials. The region has administered more than 165,000 doses of the Pfizer-BioNTech vaccine so far, which would suggest wastage of around 10,000 doses.
A similar situation is playing out in Madrid, which on Thursday announced the purchase of 280,000 syringes in order to take advantage of this sixth dose. This is a low amount, however, compared to the millions of suitable syringes that have been purchased by regions with a much smaller population, such as Murcia and the Balearic and Canary Islands. The Madrid region has stated that in “the majority of cases” it is managing to use the sixth dose, but it has offered little extra information.
Aragón, which purchased 1,870,000 syringes in September, says that it has managed to use “100% of the first five doses from each vial and 81% of the sixth, which is 97% of the total.” Castilla-La Mancha, meanwhile, puts the percentage at 90%, while Asturias, Castilla y León and the Basque Country opted not to provide figures when consulted by EL PAÍS. The rest of the regions, however, stated that the use of the sixth dose is widespread across their territories.
Meanwhile, Spain’s regions are having to improvise a response to news that politicians, retired health workers and relatives of medical staff are jumping the line and receiving the Covid-19 vaccine ahead of their time. Currently, Spain is still in the first stage of the vaccination campaign, which is focussing on senior home residents, their carers, front-line medical workers and adults with serious disabilities.
The Health Ministry and the country’s regions have been working on the vaccination plan since September, but the scheme has failed to adequately set out how the order of the vaccinations should be supervised, and whether there should be some kind of sanction or punishment for those who jump the line or indeed what to do with unused doses.
The excuses offered so far by those who have got the vaccine early range from “wanting to boost confidence” in the vaccination, to claims of making use of “leftover doses.”
EL PAÍS has requested information from the country’s health departments as to the measures being taken against these irregularities. The majority have not responded. Extremadura, Madrid and Navarre claim that they are observing protocols, while Valencia, La Rioja, Andalusia and the Basque Country explain that they are cross-referencing databases: anyone who is found to have been given the vaccine despite not being on the list of phase one recipients must offer an explanation.
Health Minister Salvador Illa said this week that “proper planning” must be put in place to avoid wasting injections, adding that any sanctions for breaking protocol are the responsibility of the regions. For now, none of Spain’s regional governments have confirmed whether or not they have levied sanctions against offenders.
No second dose
One decision that has been made, however, is that Valencia is opting not to administer the second vaccine dose to anyone who has jumped the line. This includes, for example, the Socialist Party (PSOE) mayors of the municipalities of El Verger, Els Poblets and Rafelbuñol, who were found to have skipped the protocol and were given the vaccines in senior homes.
The PSOE premier of the region, Ximo Puig, has taken the decision not to administer the second dose to the 150 to 185 people thought to have jumped the line. They will instead be fully vaccinated when it is their turn, he insisted.
But Fernando Simón, the director of the Health Ministry’s Coordination Center for Health Alerts (CCAES) and the government’s most visible face during the coronavirus crisis, criticized the approach. “I understand that people who were vaccinated when they shouldn’t have been should admit their responsibility,” he said when asked by reporters about the incidents. “But from my point of view, I believe it would committing two errors: vaccinating people ahead of time and not administering the second vaccine.”
The issue is whether it is worse to waste the first dose by not giving the second one 21 to 42 days later, as stipulated by the manufacturer, or to fully immunize those who jumped the line. The Pfizer-BioNTech vaccine needs two doses for the recipient to develop 94% immunity to Covid-19, according to clinical trials. The regional government has said that it respects Simón’s opinion but that this was “a matter of institutional credibility.” The aforementioned mayors who jumped the line have been suspended from the party and their local councils will be deciding whether or not they should be fired.
Coronavirus cases in Spain officially top two million
The number of coronavirus cases recorded in Spain since the beginning of the pandemic officially exceeded two million on Thursday, amid warnings of difficult weeks ahead. According to the Health Ministry’s latest report, all data points clearly indicate that the pandemic continues to follow an upward trend. Thursday’s report – which also included figures from Wednesday as it was a public holiday (the Health Ministry does not release data on holidays or over the weekend) – registered 42,360 new coronavirus cases. The 14-day cumulative number of cases per 100,000 inhabitants now stands at 321, up from 296 on Tuesday. The number of Covid-19 patients in hospital and intensive care units (ICUs) rose by 1,514 and 134, respectively. Thursday’s report added 245 Covid-19-related deaths to the official toll.
But the Health Ministry does not believe the rising trend will impact the return to school, which has already happened in some regions, and will begin on Monday in others. When asked about the possibility of closing schools on Thursday, health official María José Sierra replied: “We do not recommend it.”
“It [schools] is one of the areas that have worked best, where there has been the most control. There were no outbreaks,” said Sierra, from the Health Ministry’s Coordination Center for Health Alerts (CCAES), who was standing in for the center’s director, Fernando Simón. The health official highlighted the enormous social and learning impact of closing schools and said that any new measures would target sectors that are hubs for contagions.
On the question of a new home lockdown, which has been introduced in countries like the United Kingdom, Sierra replied: “There are many measures to take before a strict confinement.” The health official defended the use of partial restrictions, like perimetral lockdowns and limits on social gatherings, which “proved their effectiveness” during the second wave of the pandemic. On November 9, Spain recorded its highest incidence rate when the 14-day cumulative number of cases per 100,000 inhabitants reached 529. The incidence rate began to fall after that date until rising again at the beginning of December.
It is important to note that Thursday’s report recorded a 25-point rise in Spain’s incidence rate even though the 14-day cumulative number includes three public holidays (Christmas, New Year’s Day, King’s Day), when there is typically underreporting. What’s more, fewer PCR and antigen tests have been carried out: while 140,000 tests were being done every day in the middle of December, between December 28 and January 3 – the last week with complete data – only 110,000 tests were administered in the entire week.
With fewer tests being done – most of which are carried out on patients with symptoms –, the positivity rate i.e. the percentage of tests that come back positive out of the total, has also risen. While 20 days ago this figure stood at 8%, it rose to 13.5% last week and to 15.6% on January 4. But experts warn the rise suggests that many chains of transmission are going undetected.
“It is a trend that is worrying us,” said Sierra on Thursday, who added that the weekly positivity rate exceeded 15% in five regions and 20% in three. “Among suspected cases diagnosed in primary healthcare centers, [the positivity rate] is already close to 30%,” she added.
According to Thursday’s report, Extremadura has the highest incidence rate in Spain, recording a 14-day cumulative number of cases per 100,000 inhabitants of 717. It is followed by the Balearic Islands (529) and Madrid (452). Asturias, Andalusia and the Canary Islands are the only regions where the incidence rate is below 200.
Hospital and ICU admissions – considered one of the most objective indicators of the pandemic – also rose significantly since Tuesday. A total of 14,543 Covid-19 patients are currently admitted to hospital, occupying 11.9% of all hospital beds. The occupancy rate in ICUs is 24%, with 2,307 patients in intensive care.
Sierra confirmed that Spain has detected nearly 50 cases of the new, more contagious strain of the coronavirus that was discovered in the United Kingdom, while many more cases are being studied.
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