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      COVID-19 in Spain: view from the eye of the storm

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          Abstract

          An earlier start to the second COVID-19 epidemic wave in Spain compared with other European countries has raised overt criticism to their public health administrations’ response. 1 We want to contribute to this debate constructively, sharing our perspective as public health professionals involved in the response, even if many aspects are outside our direct remit. Spain greatly increased its response capacities after the first wave of this virus. An improved test-trace-isolate strategy was implemented in May and, by late June, more than 80% of patients suspected to have COVID-19 were PCR-tested within 24–48 h, and 90% of patients had their contacts traced (Monge S, unpublished). PCR capacities were similar to that of other countries 2 and have been further strengthened (with a current national weekly testing rate of 2·563 per 100 000 inhabitants), 3 and the public health workforce has increased by three times. 3 On the basis of a national seroprevalence study, 4 we estimate the current detection capacity to be at 60–80% of infected individuals. All strategies and protocols were integrated into an updated early response plan, adapted at the regional level, including provisions for increasing epidemiological surveillance, test-trace-isolate procedures, strategic reserves, and health-care capacity, among others, which was adopted in July. However, weaknesses persist in the system, with chronic underinvestment in primary health care, public health, digitalisation, research and innovation, bureaucratic procedures, and with little availability of trained professionals. Difficult decisions are being made, weighing scientific evidence, uncertainties, feasibility, and costs. Collaboration between public health administration and more than 30 scientific societies 5 has been ongoing since January, and external experts have advised strategic decisions. Multiple interterritorial working groups exist, at levels from technical to highly political, meeting at least once per week, achieving fluent interterritorial dialogue and coordinated decision making. Extensive and transparent information for daily epidemic monitoring is available, 3 based on exhaustive individual case information received daily at the national level. The wider availability of detailed data can help to strengthen scientific community engagement and increase public trust; work is ongoing in this direction. Evaluation is a key component for system improvement. Thus, the WHO-proposed intra-action review has been done at the national level (report under development). Wider evaluations (of which the terms of reference are in progress) and epidemiological research can further elucidate the main factors influencing the progression of the epidemic, and the short-term and long-term changes that are most needed. Factors such as existing susceptible and hard-to-reach groups, structural inequalities, population age (among the oldest in the world), limits in welfare policies, cultural and social interactions, and high mobility rates should be accounted for to explain the epidemic in Spain. In the current scenario, maintaining and further strengthening response capacities are challenges for all who are involved; community engagement and the effective implementation of control measures need to overcome pandemic fatigue. Politicisation and an unfortunate climate of confrontation permeating different sectors makes effective crisis communication challenging and is likely to impair response efforts.

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          Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study

          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.
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            Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe

            The COVID-19 pandemic is an unprecedented global crisis. Many countries have implemented restrictions on population movement to slow the spread of severe acute respiratory syndrome coronavirus 2 and prevent health systems from becoming overwhelmed; some have instituted full or partial lockdowns. However, lockdowns and other extreme restrictions cannot be sustained for the long term in the hope that there will be an effective vaccine or treatment for COVID-19. Governments worldwide now face the common challenge of easing lockdowns and restrictions while balancing various health, social, and economic concerns. To facilitate cross-country learning, this Health Policy paper uses an adapted framework to examine the approaches taken by nine high-income countries and regions that have started to ease COVID-19 restrictions: five in the Asia Pacific region (ie, Hong Kong [Special Administrative Region], Japan, New Zealand, Singapore, and South Korea) and four in Europe (ie, Germany, Norway, Spain, and the UK). This comparative analysis presents important lessons to be learnt from the experiences of these countries and regions. Although the future of the virus is unknown at present, countries should continue to share their experiences, shield populations who are at risk, and suppress transmission to save lives.
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              COVID-19 in Spain: a predictable storm?

              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.
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                Author and article information

                Journal
                Lancet Public Health
                Lancet Public Health
                The Lancet. Public Health
                The Authors. Published by Elsevier Ltd.
                2468-2667
                7 December 2020
                January 2021
                7 December 2020
                : 6
                : 1
                : e10
                Affiliations
                [a ]Centro de Coordinación de Alertas y Emergencias Sanitarias, Ministerio de Sanidad, Madrid 28014, Spain
                Author notes
                [†]

                Signatories: Silvia Rivera Ariza, Elena Vanessa Martínez Sánchez, Óscar Pérez Olaso, Pello Latasa, Bernardo R Guzmán Herrador, Lidia Redondo-Bravo, Montserrat Gamarra Villaverde, Jesús Pérez Formigó

                Article
                S2468-2667(20)30286-3
                10.1016/S2468-2667(20)30286-3
                7833953
                33301724
                © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC-BY 4.0 license

                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.

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