The Spanish Health Ministry and regional authorities on Wednesday approved a traffic light system to determine coronavirus restrictions based on an area’s epidemiological situation. This set of common criteria is to be applied until 70% of the population and all over-50s are vaccinated against Covid-19.
The traffic light system categorizes risk as extreme, high, medium, low and new normality based on data points such as the seven-day and 14-day incidence rate, and the percentage of hospital and intensive care unit (ICU) beds occupied by Covid-19 patients. The system, which applies to areas with more than 10,000 inhabitants, then recommends different restrictions based on the level of risk. Up until now, this has been used just as a guide. But on Wednesday, the Inter-Territorial Council of the National Health System (CISNS), which brings together health chiefs from the central and regional governments, voted to make it legally binding.
This means that the regions – which are in charge of controlling the pandemic as well as the Covid-19 vaccination drive – must follow the rules set out by the system. For example, even in a low-risk scenario, nighttime venues must close at 3am and only a maximum of 10 people are allowed to a table in sidewalk cafés. Catalonia, Madrid, Andalusia, Galicia, Murcia and the Basque Country have opposed the mandatory condition of the measures, which will come into force soon, once they are published in the Official State Gazette (BOE). These regions are home to 29.5 million people – more than half Spain’s population of 47.5 million. Castilla y León and the North African exclave city of Melilla also abstained from the vote.
According to the latest figures from the Health Ministry, 18,426,204 people in Spain have received their first dose of a Covid-19 vaccine – 38.8% of the population. Meanwhile, 9,679,187 people have got the full protection offered by the immunization – 20.4%. The government has set the target of vaccinating 70% of the population by the end of the summer, a target that is on track assuming there are no setbacks such as interruptions to supply. The Health Ministry on Wednesday reported 4,984 new coronavirus infections and added 66 fatalities to the overall death toll. The 14-day cumulative number of coronavirus cases per 100,000 inhabitants, meanwhile, fell a further two points to 118.
The new rules agreed on Wednesday, and which will be approved via a Declaration of Coordinated Action (DAC), may lead to legal conflicts between the Health Ministry and some regional governments. Madrid has already announced that it will follow its own measures – not those outlined by the traffic light system. In a message posted on Twitter, Madrid premier Isabel Díaz Ayuso said: “Hospitality establishments are safe spaces and our allies to overcoming this crisis. They cannot pay for the inefficiency of the Sánchez government,” in reference to Prime Minister Pedro Sánchez who leads a coalition government made up of the Socialist Party (PSOE) and junior partner Unidas Podemos.
Madrid has been at loggerheads with the central government over the reach of coronavirus restrictions since the health crisis began. When the CISNS agreed last October that areas at certain risk levels should be placed under perimetral lockdown – a decision that affected 10 municipalities in Madrid – the Ayuso government applied the restrictions, but challenged them in court. When a judge ruled in the region’s favor, the central government was forced to declare a state of alarm in the region to ensure the coronavirus restrictions were followed. Madrid also opposed the coronavirus restrictions approved by CISNS for the Christmas vacations and Easter break, such as limits on travel and social gatherings, but did eventually adhere to them.
At the end of the CISNS meeting on Wednesday, Health Minister Carolina Darias reiterated that it was mandatory for the regions to follow the measures approved by the council. “It is very important to be at a low [risk] level, not only so that we are safer and the virus is spread less, but also so that we can start entering the new normality,” she said. “We have to learn from the lessons learned. We know what happened last summer [when increased social activity led to a second wave of the virus]. What’s important is finishing off what we are achieving and reaching incidence rates below 50 [cases per 100,000 inhabitants, the threshold for low risk].”
The measures approved will affect Spain’s 17 regions differently, depending on what restrictions are already in place in each territory and their contagion rates. While some regions will be able to ease restrictions, others will have to toughen them. In Madrid, for example, the 14-day cumulative number of coronavirus cases per 100,000 inhabitants is 165, a data point, among others, that places it in the high-risk category. Despite this, the restrictions in the region correspond to those in the “new normality” category, i.e. regions where the incidence rate is 25 cases.
Andalusia allowed nighttime venues to reopen until 2am after the state of alarm came to an end on May 9. But these venues will have to close once the new rules are published in the BOE, given that the 14-day cumulative number of cases per 100,000 inhabitants in the region now stands at 177 and is continuing to rise. On the other hand, Valencia, which is in a low-risk scenario, could already allow nighttime venues to open until 3am. Hospitality establishments, however, will still need to shut by 10pm until next week.
One of the mandatory rules that must be applied regardless of the risk level is the ban on smoking when a two-meter distance from other people cannot be respected. This ban also applies to water pipes, hookahs and other ways of inhaling tobacco.
Here is an overview of the main coronavirus restrictions set down by the traffic-light system.
Low risk and new normality. Indoors, the maximum capacity is 50%. Outdoor areas will be allowed to operate at full capacity, provided that the seats between different tables are 1.5 meters apart. The consumption of food and drinks, both inside and outside, will have to take place while seated at tables, with the same safe distance. The tables will have a limit of six people inside and 10 outside. Closing time will be 3am at the latest, and registers will be introduced to ensure that patrons can be traced should a coronavirus case be detected.
Medium risk. If the progress of the health crisis is favorable, closing time will be at 2am and the same measures for the lower risk scenario will be adopted, apart from a limit of a third of capacity inside.
Bars and restaurants
New normality. The permitted capacity will be 50% inside with the option of an extra 10% if risk-control measures are introduced that guarantee high levels of ventilation and air-quality control. Tables in outdoor areas can be fully occupied provided that the distance between chairs at different tables is at least 1.5 meters. Service and consumption at the bar are allowed, provided the aforementioned distance is respected. Six people can share a table inside, and 10 outside. Closing time will be 1am and service will cease one hour previously.
Low risk. The same measures as in the new normality, but with a distance of two meters between tables.
Medium risk. Inside, the same measures as low risk, but with a limit of a third of capacity. Outside, a maximum of 75% and six people per table.
High risk. Indoor areas will be closed and the same measures will be applied outside as for medium risk.
Very high risk. Outdoor capacity limited to 50% and limits on opening times, with groups of patrons separated and a maximum of four people per table. If the trend is rising and exceeds 500 cases per 100,000 inhabitants over 14 days, establishments must close, only offering takeaway or delivery for consumption at home.
New normality. A maximum of 10,000 people. Independent sectors of no more than 1,000 people must be established, with safety measures being observed at all times. Transit areas between these sectors will be at least two meters wide. Smoking will not be permitted, nor the use of electronic cigarettes, in areas dedicated to the public. Maximum capacity of 50%, guaranteeing a useable area of 1.5 square meters per person, and eating and drinking will not be allowed in the public areas.
Low risk. The same measures as previously described, but with a maximum of 5,000 people and space of 2.25 square meters.
High risk. A maximum of 2,500 people. If possible, independent sectors of no more than 500 people will be established. Capacity will be limited to 30% and the area per person will be three square meters. Consumption of food and drink will be prohibited.
Very high risk. No events with large crowds will be allowed.
Primary and secondary school, vocational training. These centers will remain open during the entire school year, “ensuring there are canteen services as well as out-of-hours study support for minors with special needs or who belong to socially vulnerable people,” according to the document, to which EL PAÍS had access on Tuesday. If there are outbreaks or the transmission of the virus runs out of control, “mixed in-person and remote education will be considered” before the center is closed, or “changes to the timetable that will allow for greater limits on contacts.”
Universities. The agreement only stipulates “distance learning as far as possible” for university teaching under alert level 4, and for the rest of the levels the same recommendations will be in place as for 2020 to 2021 – i.e. the use of masks, a Covid coordinator, contact tracing, quarantines for those with symptoms and ventilation of closed spaces, among other measures.
For all centers. All of the prevention measures set out by the ministry will be applied in all schools and universities. These include limiting contacts, maintaining social distancing, creating bubbles, handwashing and mask use, regular ventilation of indoor areas and students with symptoms staying at home.
Fourth coronavirus wave plateaus in Spain, but hospitals remain under pressure
The report released on Thursday by the ministry shows that the 14-day cumulative number of coronavirus cases per 100,000 inhabitants for the country as a whole remains high, at 232.55. But it barely rose three points on the day before, after two days with no change. The experts attribute this to the vaccination campaign and the ongoing social restrictions in most of the country, but they also warn that the situation in Spain is far from good – seven regions and the two North African exclave cities, Ceuta and Melilla, are at “extreme risk” levels, with an incidence above 250, and one in every five intensive care unit (ICU) beds is occupied by Covid-19 patients. Thursday’s report added 132 deaths to the official toll, which now stands at 77,496.
This wave can’t be compared with the previous ones and it appears to be stabilizing now
JESÚS MOLINA CABRILLANA, SPOKESPERSON FOR THE SPANISH SOCIETY OF PREVENTIVE MEDICINE, PUBLIC HEALTH AND HYGIENE
“Caution and prudence,” insists Daniel López-Acuña, a former director of emergencies at the World Health Organization (WHO). After more than a month that has seen the incidence rising – the curve started to go up on March 16 – the 14-day cumulative incidence has plateaued for the last week. On Monday it came in at 230, and by Thursday it had gone up by 2.55 points. “We are in a plateau phase, taking one step forward and one step back,” explains Toni Trilla, head of preventive medicine at the Hospital Clínic in Barcelona. “Perhaps the health system will not suffer so much and I hope that there is a consolidated fall, but we are a bit confused because this wave has not followed the pattern of other waves.”
Some epidemiologists point to the seven-day cumulative incidence, which also confirms the plateau. This data point has been hovering around 108 cases per 100,000 inhabitants in the last seven days, less than 50% of the 14-day figure. “If the seven-day incidence is below 50% of the 14-day incidence, that means that the curve is falling,” explains Jesús Molina Cabrillana, spokesperson for the Spanish Society of Preventive Medicine, Public Health and Hygiene. “This wave can’t be compared with the previous ones and it appears to be stabilizing now. In any case, if there is an uptick, it won’t be a big one. More than a week has now passed since Easter, which is when there could have been an increase in infections, and it is not expected to rise further.”
The speed of transmission of the virus in Spain – the R number, which measures on average how many people a person with the coronavirus infects – is also falling. On April 14, the last day for which there is data, the number had fallen below one for the first time in a month – that is the limit below which the health authorities say that the virus is under control. On that day, it came in at 0.98 – that’s to say, for every 100 positives, another 98 people will be infected. “It is good for this to continue like this,” explains López-Acuña. “But what should guide us is that, if we continue to have a plateau and incidences that are very high and intensive care units with such high occupation, we should be concerned.”
What is clear from the data is that the epidemiological situation varies greatly from region to region. Valencia, for example, is below 40 cases per 100,000 inhabitants, the lowest level in Spain. Galicia, the Balearic Islands and Murcia are also under 100. Madrid and Navarre, however, are as high as 400 cases per 100,000 inhabitants while the Basque Country exceeds 500 cases.
“The overcrowding of people can have a big influence,” explains epidemiologist Joan Caylà. The population density is not the same in Galicia as it is in the metropolitan area of Barcelona. In the case of the Valencia region, what they do very well there is contact tracing and that can be a determining factor for isolating cases and imposing quarantines.”
The toughness of the measures in place – each region can decide its own restrictions – and compliance with the rules, the experts say, constitute another of the determining factors that are seeing the epidemiological curves fluctuate. Valencia, for example, has taken very strict measures and is deescalating very slowly – bars have to close at 6pm, a restriction that is due to be lifted on Monday. Madrid, meanwhile, with an incidence that is 10 times higher, has been a lot laxer with restrictions. Restaurants, for example, are staying open until 11pm.
The experts also assume that the vaccination campaign has also played a key role in the progress of this wave, but there are several nuances here. With just 21.4% of the population so far protected with one shot of the Covid-19 vaccines being used in Spain, above all in the older age groups, the epidemiologists agree that the vaccine has not had such an influence on the infection curve, given that most of the new cases are being registered among young people who have not had the chance to get their shots yet. The big effect, they say, is in terms of the fall in deaths and hospitalizations, where age is a key factor. Vaccination “will have had an influence on the curve of infections,” explains Molina Cabrillana, “but where it has really contributed is with serious illness and mortality. There is currently not the kind of overloading [of hospitals] that we saw in November and January.”
Spain’s ICUs were facing this fourth wave from a starting point of high hospital occupation. On March 16, for example, 20% of beds were occupied by Covid-19 patients, and healthcare professions feared a wave of new cases after Easter week. However, admissions have not, for now, shot up. On Thursday, there were 2,283 coronavirus patients in a critical condition – that is 22.6% of the available ICU beds.
López-Acuña insists on the need for prudence in the current situation. “It is likely that the magnitude of the wave is not so pronounced because there is less mobility than at Christmas, fewer crowds and a segment of the population is protected [by vaccines]. But there are a few worrying elements: community transmission is not under control, and there is an ongoing high occupation of ICUs, with the most severe cases linked to the British strain, which leads to longer hospital stays.” This variant, which is more infectious and was first identified in England, has been predominant in Spain since March.
The experts all coincide with López-Acuña and call for the social restrictions in place and protection measures to be respected, and for people not to drop their guard ahead of time. “The impact on the healthcare system will have to fall if the speed of vaccination accelerates, but it will take time before we see this in terms of infections,” explains Trilla. The European Center for Disease Control (ECDC) has issued a recommendation stating that two people should be able to remove their masks in a closed space if both of them are vaccinated, as well as calling for a relaxation of quarantine and testing requirements for travel for those who have had their vaccine shots. Molina Cabrillana sees this as feasible, but Trilla and López-Acuña say that it is “premature” because it could convey a message of “false security,” and prompt an “excessive relaxation.”
As for the social restrictions, Trilla recommends “asymmetrical measures that are adapted to the scale of each region at any given time.” Molina Cabrillana is calling for people to “hold on a little longer, until we are below 50 cases per 100,000 [inhabitants].” López-Acuña, meanwhile, is insisting that “restrictions continue in closed spaces.” If there is one thing that all the experts consulted by EL PAÍS agree on, it is the major pending task: “Strict contact studies,” Caylà states.
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.
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