Sunday, October 24

Vaccination alone is not enough to stop the fifth wave

We are immersed in the fifth wave of the COVID-19 pandemic, with very high incidence rates in the general population and even higher in the population aged 12 to 39 years. Consequently, hospital pressure is growing by leaps and bounds, especially due to the admission of many people under 40 years of age. As if that were not enough, the incidence also increases in vaccinated elderly people. However, the answer to all this is not being the forceful and coordinated that is required.

A year and a half have passed since the start of the pandemic, we have suffered four bloody and painful waves, but we still do not have the appropriate leadership (both at the state level and at many regional levels) that, within the framework of the Interterritorial Council, allow us to do what is needed to ensure the application of those non-pharmacological measures that we know for sure would work to effectively prevent infections in the general population.

Since the state of alarm declined on May 9, and with it the most useful control measures for unprotected social interaction to stop transmission (such as the so-called “curfews” or the closure of nightlife) , the health authorities lost a powerful weapon for the effective coordination of effective responses.

It should be remembered that the autonomous communities opposed the initial proposal of the Ministry of Health to define mandatory measures based on the evolution of the pandemic, and that it erroneously accepted in the end, that the Declaration of Coordinated Actions in public health in the face of COVID-19, it will remain as a catalog of mere recommendations that each community will apply at its discretion.

The result is in sight: after several weeks of unstoppable growth in incidence, which has stood at 677 cases per 100,000 inhabitants in the last 14 days (with much higher figures in young ages due to their poor coverage of vaccine immunity) and With an intense growth in healthcare pressure, both in primary care and in general hospitalization and in ICUs, the response to this fifth wave is ineffective, insufficient and uneven in Spain.

As if that were not enough, the necessary intervention of the Superior Courts in the absence of a state of alarm is generating a contradictory mosaic of legal responses that is incomprehensible from the point of view of public health and, also, from the point of view of citizens. In practice, the insufficiency of the legal framework currently in force is evident, at least in the way in which government authorities are putting it into practice.

In this context, the judicial process open to the general director of public health of the Balearic Islands generates enormous concern and concern as it reveals the incomprehension of some courts about what the health protocols for control of transmission mean, which, in addition to being unfair towards the accused person, hinders the work of those who have the obligation to exercise health authority to protect the health of the population, prevent disease and save lives.

But let’s go back to the epidemiological situation. In the first place, we reiterate the need to expand the information published from Monday to Friday by the Ministry of Health (the absence of data on weekends is still incomprehensible) in order to incorporate information related to the ages and immune status of people treated and admitted to health services. It would even be of great interest to know how many of these patients have a complete schedule or at least one dose of the COVID-19 vaccine. This information would help to better understand the epidemiological situation and to better target the pedagogical and social awareness actions necessary to reinforce the contagion prevention measures that are in the hands of each citizen.

Second, the dominance of the delta variant, (surely underestimated since our measurement capacity is highly improvable), implies that its characteristics of greater contagion capacity and even of probable escape (at least partial) to acquired immunity, must be taken into account when redesigning much more interventionist policies to stop the pandemic. Wait and see may not be an option right now.

The incidence of positive cases in vaccinated people with a complete schedule (although generally asymptomatic or with mild symptoms) should lead us to assess that this fifth wave, in addition to presenting enormous incidences both in the general population and in younger population groups without immunity It does not resemble the previous waves and requires the adoption of intense and coordinated social interaction control measures throughout the territory.

The longer we have such high incidences, the greater the probability that severe cases will occur even in vaccinated people, which, although they will be few in proportional figures, may be relevant in absolute figures, with the consequent social alarm and the risk of reopening a certain (and damaging) debate on the effectiveness of vaccines. And, in addition, we will give the virus more opportunities to produce more contagious mutations or with greater vaccine escape.

This situation of lack of preventive response has exceptions (Catalonia, the Valencian Community, Cantabria, the Basque Country, Navarra or Asturias, among others) where limitations are being applied to nightlife and curfews, some of which are beginning to give results as shown. You can see in the case of Catalonia that it seems to have reached the epidemic peak and a decline is beginning that has yet to be consolidated. But, even in these cases, there is still a notable lack of concordance between measures and epidemiological situations, and a notable cacophony of initiatives and messages, which do not help the public to better understand what is happening.

In addition, the enormous pressure on primary care due to the large number of new cases and the inability to adequately attend to its epidemiological surveillance functions, with early detection, tracking and eventual quarantines, may be more affected after the incorporation of the tests over-the-counter self-diagnosis in pharmacies. This decision has been, in our opinion, quite myopic because, among other defects, the opportunity has not been taken to structurally link pharmacy offices to the epidemiological surveillance systems of the regional health services, exclusively downloading its presumed utility in the free decision of individuals, which is not the best option in terms of public health.

Undoubtedly, the excellent progress of the vaccination strategy adopted in the Interterritorial Council (Spain exceeds the vaccination rates per hundred thousand inhabitants of the United States and the United Kingdom, for example), will help mitigate the impact of COVID-19 in the population groups pending to be vaccinated. The magnificent capacity demonstrated in a general way by most of the autonomous communities, the great work of the professionals who manage the vaccine program and especially the nurses who administer them, is complemented by the positive response of the population to the call to be vaccinated.

We are now entering a phase in the vaccination process in which pedagogy efforts should continue to ensure that the younger populations awaiting vaccination respond without reluctance, and this requires not giving up any opportunity for health education and pedagogy.

However, to break this fifth wave, vaccination will not be enough: its effects are spectacular to reduce mortality, severe disease and, therefore, to curb the risk of hospitalization. But they are not so much to reduce transmission.

In short, either common and coherent decisions are adopted to apply restrictions to mobility in all territories that exceed certain thresholds, and a renewed leadership is rebuilt from the Ministry of Health, with a co-governance that provides clarity and coherence, or the high Transmission will continue, the impact on the health system (already very fatigued and stressed) will increase and the concern of citizens will increase.

And, of course, the economic recovery objectives, linked above all to tourism, will continue to be undermined. In recent weeks, various tourist-issuing countries have introduced new precautions or restrictions on the movement of their citizens to Spain.

Finally, in terms of vaccination, we still have many aspects to know from the perspective of scientific evidence before venturing what new steps we will have to take in the future, be it in relation to a possible third dose or possible vaccinations in successive years. However, there is something that we do know today, and that is that access to the vaccine either becomes universal, (and therefore benefits all the inhabitants of the planet), or it will leave an open space for the appearance of new variants with the consequent uncertainty about the future evolution of this pandemic.

In this sense, the coordinating role of the European Union, ECDC, WHO-Europe and WHO as a whole needs to be renewed and strengthened. The Covax initiative has to go far beyond what it has achieved so far if we are to meet global public health effectiveness and equity goals. And vaccine production has to be boosted globally in order to reach all countries without patents constituting a bottleneck for the effective control of the pandemic and with more effective efforts to increase production capacity with agreements between producing companies. Unfortunately, so far in this regard there have been many more words than deeds and there is still a long way to go.

The management of the pending chapters yet to be known in the evolution of this pandemic therefore advises prudence and discourages unjustified optimism. To do this, realistically addressing the situation and renewing leadership and coordination capacities at national, European and global levels seems to us an urgent requirement.