Integral management of COVID-19 in Madrid: Turning things around during the second wave.

Summary Background Spain is one of the European countries most affected by the COVID-19 pandemic. Serological surveys are a valuable tool to assess the extent of the epidemic, given the existence of asymptomatic cases and little access to diagnostic tests. This nationwide population-based study aims to estimate the seroprevalence of SARS-CoV-2 infection in Spain at national and regional level. Methods 35 883 households were selected from municipal rolls using two-stage random sampling stratified by province and municipality size, with all residents invited to participate. From April 27 to May 11, 2020, 61 075 participants (75·1% of all contacted individuals within selected households) answered a questionnaire on history of symptoms compatible with COVID-19 and risk factors, received a point-of-care antibody test, and, if agreed, donated a blood sample for additional testing with a chemiluminescent microparticle immunoassay. Prevalences of IgG antibodies were adjusted using sampling weights and post-stratification to allow for differences in non-response rates based on age group, sex, and census-tract income. Using results for both tests, we calculated a seroprevalence range maximising either specificity (positive for both tests) or sensitivity (positive for either test). Findings Seroprevalence was 5·0% (95% CI 4·7–5·4) by the point-of-care test and 4·6% (4·3–5·0) by immunoassay, with a specificity–sensitivity range of 3·7% (3·3–4·0; both tests positive) to 6·2% (5·8–6·6; either test positive), with no differences by sex and lower seroprevalence in children younger than 10 years ( 10%) and lower in coastal areas (<3%). Seroprevalence among 195 participants with positive PCR more than 14 days before the study visit ranged from 87·6% (81·1–92·1; both tests positive) to 91·8% (86·3–95·3; either test positive). In 7273 individuals with anosmia or at least three symptoms, seroprevalence ranged from 15·3% (13·8–16·8) to 19·3% (17·7–21·0). Around a third of seropositive participants were asymptomatic, ranging from 21·9% (19·1–24·9) to 35·8% (33·1–38·5). Only 19·5% (16·3–23·2) of symptomatic participants who were seropositive by both the point-of-care test and immunoassay reported a previous PCR test. Interpretation The majority of the Spanish population is seronegative to SARS-CoV-2 infection, even in hotspot areas. Most PCR-confirmed cases have detectable antibodies, but a substantial proportion of people with symptoms compatible with COVID-19 did not have a PCR test and at least a third of infections determined by serology were asymptomatic. These results emphasise the need for maintaining public health measures to avoid a new epidemic wave. Funding Spanish Ministry of Health, Institute of Health Carlos III, and Spanish National Health System.

Spain, with more than 11 000 cases and 491 deaths as of March 17, 2020, has one of the highest burdens of coronavirus disease 2019 (COVID-19) worldwide. In response, its government used a royal decree (463/2020) 1 to declare a 15-day national emergency, starting on March 15. Although the Spanish health system has coped well during the 6 weeks since its first case was diagnosed, it will be tested severely in the coming weeks as there is already widespread community transmission in the most affected regions, Madrid, the Basque Country, and Catalonia. The number of new cases in the country is increasing by more than 1000 each day. A crisis such as this places pressure on all building blocks of a health system, 2 each of which we consider in turn. The first is governance. Coordination is crucial in any country, but especially in one like Spain in which responsibility for health is devolved to 17 very diverse regions. The Health Alert and Emergency Coordination Centre (Centro de Coordinación de Alertas y Emergencias Sanitarias in Spanish), created in 2004, provides a mechanism for coordination between the national and regional governments. This mechanism has not, however, ensured that measures are fully coordinated. Thus, the Basque Country declared a public health emergency before any other region, whereas Catalonia requested a complete shutdown of the region, including closure of air, sea, and land ports. Madrid, La Rioja, and Vitoria banned gatherings of more than 1000 people. These measures were accompanied by a range of social distancing measures, including closure of schools, universities, libraries, centres for older people, and sporting venues, and even restricting all movement in some of the most affected areaS. 3 In a country in which regional autonomy has been politically important, the new decree includes a controversial measure to give the central government sweeping new powers over health services, transport, and internal affairs, including giving members of the armed forces powers of law enforcement. These measures have provoked opposition in Catalonia and the Basque Country, which have their own police forces that will now come under national control. However, the imposition of restrictions on movement of people to allow only that necessary to get to work or buy food and medicines, as well as the closure of borders does seem to have been accepted, at least so far, with only limited disagreement among the main parties on the measures adopted. The second building block is financing. Before the decree, central government adopted a series of financial measures to support the health system and protect businesses. It had allocated €2800 million to all regions for health services and created a new fund with €1000 million for priority health interventions. 4 However, these amounts need to be seen against the background of almost a decade of austerity from which the health system has yet to recover. 5 Third, in service delivery, the national Ministry of Health has developed a set of clinical protocols, published on its website. Additional advice is published by certain regions and updated, in some cases, on a daily basis. 6 Health facilities in the worst affected regions are struggling, with inadequate intensive care capacity and an insufficient number of ventilators in particular. Both Catalonia and Madrid 7 have cancelled non-emergency surgery and cleared beds where possible. COVID-19 telephone help lines have long delays or have simply collapsed in some regions. The new decree allows the regions to take over management of private health services while military installations will be used for public health purposes. The fourth block is medicines and equipment. So far, no serious shortages have been reported but supplies of personal protective equipment in health facilities have been a concern in all regions leading to re-use, despite the known risks. There is a particular shortage of face masks caused by early panic buying. These shortages have encouraged profiteering, with private laboratories, for example, charging exorbitant amounts for tests. 8 In response, the central government has centralised purchasing and introduced price controls on medicines 9 requiring companies producing relevant equipment to inform the central government of their stocks within 48 h. The fifth block comprises health workers. Many reports suggest that they are stretched to the point of exhaustion. This situation in part reflects existing staff shortages, again following years of austerity with resultant low salaries. Before the decree, patchy and insufficient measures were suggested such as cancelling holidays or bringing retired nurses and doctors back into the health service. The problems are being exacerbated by the quarantining of a growing number of health workers exposed to patients who are infected. 10 The new decree permits hiring graduates without specialisation, final year medical and nursing students, and extending contracts of medical residents. The final building block, information, is widely considered to have been provided by authorities at all levels in a timely manner via mainstream and social media. The Spanish media has largely acted responsibly, disseminating accurate information and debunking fake news stories circulating on social media networks. These developments have coincided with changing attitudes among the Spanish population. Initially, the disease attracted little attention, but this calm soon gave way to panic and hoarding of key supplies once cases began to increase. However, many manifestations of solidarity have been seen, such as supporting health professionals, those who are most vulnerable, and voluntary social distancing, including greater home working. Already, at least five important lessons can be drawn from the Spanish experience. First, additional financial resources are needed to support regional health systems, each with different initial resources and current challenges. Second, long-term underinvestment in health services, as seen in many countries following the 2008 financial crisis, impairs their resilience by depleting their ability to respond to surges in need for health care with sufficient health professionals, intensive care unit beds, protective equipment, diagnostic test kits, and mechanical ventilators. Third, although Spanish residents do seem largely to have responded responsibly so far, it will be important to draw on evidence from behavioural sciences to ensure that this conduct continues over what could be many months. Fourth, although coordination between the national and regional governments has generally been good, work will be needed to ensure this continues over the next few months, with an understanding that politicians must not be allowed to exploit the situation for political gain. Finally, once the pandemic is over, Spain will need to address the decade of underinvestment in its previously strong health sector, which has left it struggling at this time of crisis.

As of Oct 12, there have been 861 112 confirmed cases and 32 929 deaths due to COVID-19 in Spain. More than 63 000 health-care workers have been infected. Spain was one of the most affected countries during the first wave of COVID-19 (March to June), and it has now been hit hard again by a second wave of COVID-19 infections. While the reasons behind this poor outcome are still to be fully understood, Spain's COVID-19 crisis has magnified weaknesses in some parts of the health system and revealed complexities in the politics that shape the country. The COVID-19 pandemic tested health system resilience and pandemic preparedness. Despite the creation in 2004 of a Centre for Coordination of Health Alerts and Emergency, the pandemic laid bare the country's “weak surveillance systems, low capacity for PCR tests, and scarcity of personal protective equipment and critical care equipment, a delayed reaction by central and regional authorities, slow decision-making processes, high levels of population mobility and migration, poor coordination among central and regional authorities, low reliance on scientific advice, an ageing population, vulnerable groups experiencing health and social inequalities, and a lack of preparedness in nursing homes”, according to 20 Spanish public health leaders writing in August in The Lancet. The Spanish health system's four pillars—governance, financing, delivery, and workforce—were already fragile when they were overwhelmed by COVID-19 in March. A decade of austerity that followed the 2008 financial crisis had reduced the health workforce and public health and health system capacities. Health services are understaffed, under-resourced, and under strain. With 5·9 nurses per 1000 inhabitants, Spain has one of the lowest ratios in the EU (where the average is 9·3 per 1000), and too often relies on temporary contracts that can run for just a few days or weeks. Granular data surveillance is key for understanding and responding to an outbreak. For Sergi Trias-Llimós and colleagues, writing in The Lancet Public Health, the data currently published at the country and regional levels are insufficient to understand the dynamics of the epidemic. They call on authorities to provide comprehensive data updates on tests, cases, hospitalisations, intensive care unit admissions, recoveries, and deaths, all disaggregated by age, sex, and geography. The test-trace-isolate tryptic, which is the cornerstone of the response to the pandemic, remains weak—COVID-19 cases are increasing alarmingly, and authorities are again looking at lockdowns to contain the spread of the virus. When the national lockdown was lifted in June, some regional authorities were probably too fast at reopening and too slow at implementing an efficient track and trace system. In some regions, the local epidemiological control infrastructure was insufficient to control future outbreaks and limit community transmission. Spain's political polarisation and decentralised governance might also have hampered the rapidity and efficiency of the public health response. Whereas the first wave might have been unpredictable, the second wave in some parts of Spain was quite predictable, Rafael Bengoa (Institute for Health and Strategy, Bilbao, and former Minister of Health Basque Country) told The Lancet Public Health. In an attempt to identify areas where public health and the health and social care system need to be improved, Alberto García-Basteiro and colleagues, in their Letter in The Lancet Public Health, urged the Spanish central and regional governments to set up an independent evaluation of their COVID-19 responses, and lay down the requirements and principles for such an evaluation. The evaluation should start immediately, should build consensus among society, and requires firm commitment from the central and regional governments; the evaluation committee should be independent, diverse and multidisciplinary, the evaluation should be broad in scope (health, economic, and social effects) and providing recommendations. Such an independent evaluation will be key to reassure the population and rebuild trust in the Government's approach to public health. And there are reasons for hope. In the latest Global Burden of Disease analysis, published in The Lancet, health indicators (such as life expectancy and healthy life expectancy) suggest that Spain overperforms, with indicators better than would be predicted according to the country's socio-demographic index. If Spain's political leaders can draw the lessons from their sub-optimal response to COVID-19, the country is very well placed to give its population a bright and healthy future. © 2020 Marcos del Mazo/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.