3. Providing health services effectively
The section on PROVIDING HEALTH SERVICES EFFECTIVELY describes approaches for service delivery planning and patient pathways for suspected COVID-19 cases. It also considers efforts by countries to maintain other essential services during periods of excessive demand for health services.
3.1 Planning services
On April 26, the Centre for the Coordination of Health Alerts and Emergencies, collecting the contributions of the scientific community and experts, yielded a document with recommendations for the health system during the transition period. The recommendations aim to step-back to a contention strategy and assure the rapid response of the health system in the eventual case of an increase in the incidence of cases, while assuring equitable and safe access to non-COVID patients. The document includes as recommendations:
-Preventive measures such as physical distancing, respiratory etiquette, hand hygiene or the use of masks by the general population have to be reinforced, following the recommendations issued by the Ministry of Health and regional health authorities.
-Public Health authorities should design and implement new protocols to achieve early detection and monitoring of new cases. For that purpose, early identification and isolation of new cases, early identification and quarantine of contacts, particularly in nursing homes or prisons, should be reinforced. In addition, any data source that can inform on the appearance of new cases and contacts should be included as part of the surveillance system.
-Health care settings, such as hospitals or primary care centres, will have to assure non COVID patients assistance while keeping capacity to deal with potential future COVID-19 outbreaks; as follows: for hospitals, to prevent nosocomial infections at any hospitalization area and to assure sufficient personal protective equipment. These measures could be complemented by differentiating internal flows between COVID and non-COVID patients or, depending on the epidemiological situation, performing screening PCR tests to any admitted patient. In addition, hospitals have to be able to double ICU beds, triple hospitalization beds and store sufficient ventilation equipment and medication to cope with the epidemic upsurge.
-For primary care centres, to dedicate specific spaces to treat COVID patients, design specific circuits to separate respiratory and infectious patients, reinforce home care and telemedicine, along with public health authorities to set up early detection and surveillance protocols, and adopting the use of apps to detect and monitor patients and trace their contacts.
-Finally, healthcare settings should be able to offer consultation for screening, diagnostic, surveillance and psychological support to their workforce (https://www.mscbs.gob.es/gabinetePrensa/notaPrensa/pdf/25.04260420153138925.pdf).
Once the state of alarm expires, regional health authorities have to guarantee the responsiveness and coordination among public health, primary care and hospital care. Likewise, primary care centres and hospitals should have plans (organization and resources) for rapid response if sudden increases in the number of infected cases occur (Royal Decree 21/2020 https://boe.es/diario_boe/txt.php?id=BOE-A-2020-5895).
On July 16, the Ministry of Health and the autonomous communities agreed a plan for an early response in case of an increase in COVID-19 transmission. The plan foresees strengthening health services preparedness for COVID-19 outbreaks, increasing public health capacity for the early detection and COVID-19 control, and population-oriented preventive measures (https://www.mscbs.gob.es/gabinetePrensa/notaPrensa/pdf/17.07170720140919256.pdf).
In the Interterritorial Council held on September 9, the Ministry of Health and the autonomous communities agreed on developing a common vaccination strategy taking into account bioethics’ experts and scientific societies’ opinions. This common vaccination strategy will be approved in a plenary session of the Interterritorial Council. Autonomous communities will have to provide all the required resources to administer the vaccines that will be provided, in turn, by the Ministry of Health (https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=5048).
VACCINE SERVICES AND DELIVERY
On November 24, the Ministry of Health presented the COVID-19 Vaccination Strategy. Vaccination will be voluntary and free of charge.
To prioritize those most vulnerable groups, the Spanish population has been divided in 15 groups that will be vaccinated in three consecutive stages, corresponding to the first three trimesters of 2021. The decision on which groups will be vaccinated first will be agreed according to scientific, ethical, legal and economic criteria. So, priority will be decided according to risk of severe morbidity and mortality, risk of exposure, socioeconomic impact and risk of transmission.
So, older people and disabled institutionalized people, health and social care personnel in care institutions and non-institutionalised dependent populations -meaning 2.5 million people- will be the first groups to receive the COVID-19 vaccine in the first trimester.
This Strategy, that will be implemented at regional level, is based on the recommendations of the European Commission and other international institutions (ECDC, WHO), and has been elaborated by the COVID-19 Vaccination Technical Working Group (made up of regional representatives and experts) and the Vaccine Committee, both bodies of the Interterritorial Council of the National Health System (https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=5142; https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=5148; https://www.mscbs.gob.es/gabinetePrensa/notaPrensa/pdf/24.11241120144431769.pdf).
COVID-19 vaccination will start on December 27. According to the first update of the COVID-19 Vaccination Strategy published on December 21, first vaccine doses will be administered to residents and workers in assisted-living nursing homes as well as care centres for highly-disabled people. At this first stage, front line healthcare and social care workers will also be vaccinated. Once these two groups are completed, other health and social care workers and non-institutionalised highly dependent people will get the vaccine (COVID-19 Vaccination Strategy: https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID-19_EstrategiaVacunacion.pdf. Update on the Strategy: https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID-19_Actualizacion1_EstrategiaVacunacion.pdf).
According to the second update of the COVID-19 Vaccination Strategy published on January 21, people older than 80 years old will be the next group to be vaccinated (https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID-19_Actualizacion2_EstrategiaVacunacion.pdf).
On February 5, the Public Health Commission within the Interterritorial Council authorised the administration of the AstraZeneca-Oxford vaccine to people between 18 and 55 years old. Priority has been given to those health care and social care workers not included as first-line professionals and other essential workers (e.g. firemen or policemen) (https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=5216). On February 9, new groups were deemed eligible for the AstraZeneca vaccine, such as physiotherapists, occupational therapists, chemist’s assistants, and prisons’ workers. In addition, groups with an essential activity for the society including security forces, emergency personnel, the army as well as teachers in special, infant, primary and secondary schools. (https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID-19_Actualizacion3_EstrategiaVacunacion.pdf;https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=5222).
On February 17, the Public Health Commission agreed that population cohorts between 60 and 79 will be the next getting mRNA vaccines, starting from those over 70. In addition, the population under 60 with high-risk conditions has been also deemed eligible for mRNA vaccines. On the other hand, the next group to be vaccinated with the AstraZeneca vaccine will be the population from 45 to 55 years old (https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=5232).
A new update of the Vaccination Strategy has been published on February 26. Two major decisions are set up in this update. On the one hand, the next group deemed suitable for mRNA vaccines are individuals with high-risk conditions from 56 to 59 years old. On the other, guidance is provided on those people who have had COVID-19; thus, people over 55 will keep receiving the two vaccination shots, whereas people over 55 and SARS-CoV-2 diagnosed after receiving the first dose, will receive the second dose once they are completely recovered and the isolation period is over. Regarding people under 55, they will receive just one shot 6 months after the infection, while those under 55 and SARS-CoV-2 diagnosed after receiving the first dose, will receive the second dose after six months.
Finally, serologic tests are not recommended either before, as a confirmation of a previous infection, or after the vaccination to test if there is an antibody response to it (https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID-19_Actualizacion4_EstrategiaVacunacion.pdf).
The roll-out of the Astra-Zeneca vaccine has been suspended from March 16 to March 23 as a precautionary measure because of the possible link between the vaccine and clots. In light of the new findings, the Public Health Commission will redefine the groups to be vaccinated with this vaccine weighing up an increase of the age limit and the exclusion of groups with a higher risk of blood clots associated with thrombocytopenia (https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=5270).
On March 22, in accordance with the new evidence available, the Interterritorial Council decided to extend the age limit to receive AstraZeneca vaccine from 55 to 65 years old and as from April, there is no age-limit for essential workers (https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=5274).
These age limit changes are included in the fifth update of the Vaccination Strategy, published on March 30, which also describes the high-risk groups that will be vaccinated with mRNA vaccines simultaneously with people from 70 to 79 years old. Among others, people who endured a transplant or is waiting for one, onco-haematologic patients, cancer patients receiving chemotherapy, people in dialysis, people over 40 with Down syndrome or immunodepressed HIV patients.
In addition, according to new evidence, people under 65 (instead of 55) who have had COVID-19 will receive just one shot 6 months after the infection.
The document also states that vaccines are indicated according to their efficacy and indications in each population subgroup, so people cannot choose which vaccine to receive, thus preserving the ethical values of the strategy (https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID-19_Actualizacion5_EstrategiaVacunacion.pdf).
On April 7, considering the latest report by the EMA on the Astra-Zeneca safety events, the Ministry of Health together with the autonomous communities agreed on suspending the administration of the Astra-Zeneca vaccine to people under 60 years old. Until new evidence is available, this vaccine will be administered to people from 60 to 69 years old. The decision on whether to provide a second shot of Astra-Zeneca vaccine or whether to use a second jab from a different vaccine has been postponed until more evidence is available. Keeping just one shot is also open as a possibility.
On April 19 the clinical trial CombivacS was presented. Promoted by the Carlos III Institute of Health (ISCIII) the study aims to assess if people that have received only one dose of the AstraZeneca vaccine have generated enough antibodies or, on the contrary, they need a booster dose.
The study has enrolled, in 5 different hospitals, 600 volunteers under 60 years old who have already received the first shot of the AstraZeneca vaccine. 400 volunteers will be given the second dose of Pfizer, and their antibody levels will be compared 14 days later to those of the control group (200 people) who will not receive any additional shot (https://clinicaltrials.gov/ct2/show/NCT04860739).
On April 20, the Public Health Commission approved the sixth update of the Vaccination Strategy that, taking EMA’s recommendation, decided to use Jansen’s vaccine on people aged 70 to 79. In addition, the 6th update recommends immunization to essential workers older than 60 with other vaccines than Astra-Zeneca’s.
This latest update also describes the first results on the immunization effectiveness in living-assisted and nursing homes. Specifically, the risk of infection among residents decreased 57% in the 14 days after the first dose and up to 81% after the second dose. Furthermore, people not vaccinated living in residences with high vaccination coverage were observed to be protected (https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=5306; https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID-19_Actualizacion6_EstrategiaVacunacion.pdf).
On April 30, the Public Health commission agreed on extending from 12 to 16 weeks the interval between the first and second dose of AstraZeneca vaccine for people under 60 who have already received the first dose. This extension will allow gathering more information about secondary effects of the second dose in people under 60 and results from clinical studies assessing the use of a different vaccine as a second dose (https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=5318).
Since the second week of March, as a response to the increasing toll of cases, elective surgery and non-urgent consultations have been postponed. In turn, primary care centres have also called off non-urgent consultations, cancelled emergency care except for patients with respiratory symptoms, and implemented an e-prescription mechanism for chronic patients so they can get their prescriptions renewed automatically, and thus avoid a visit to primary care premises. Along the same lines, phone helplines and on-line consultations have been used to deal with non-essential cases.
Since 14 March, after the declaration of the “state of alarm”, the Minister of Health was temporarily entitled to determine the best distribution of technical resources, including those from the military forces, private health sector, and even private business as hotels (Royal Decree 463/2020 https://www.boe.es/buscar/doc.php?id=BOE-A-2020-3692). As a consequence, from March 15, ACs can make use of private healthcare centres (including their personnel) and those of the mutualities for accidents and occupational diseases, if needed. Private hospitals that are treating privately insured patients with COVID-19 are also receiving patients from overcrowded public hospitals or treating non-COVID-19 patients, to release hospital beds and increase physical distance.
In addition, health authorities are entitled to make public or private spaces available (e.g. sports arena) to build ambulatory and hospital care premises (Order SND/232/2020 https://www.boe.es/buscar/act.php?id=BOE-A-2020-3700). So for example, on March 31 there were 16 field hospitals, most of them in Madrid, set up to specifically admit and treat the less severe cases. For example, a temporary field hospital with 1,300 beds has been set up in IFEMA, Madrid’s exhibition centre (https://www.lamoncloa.gob.es/serviciosdeprensa/notasprensa/defensa/Paginas/2020/310320-hospitales.aspx).
Finally, in some regions, hotels have been adapted to allow the recovery of patients and relieve overloaded hospitals (Orden TMA/277/2020 https://boe.es/buscar/act.php?id=BOE-A-2020-4027).
It is also worth noting that the Spanish Government has established legal provisions to ease subcontracting procedures with public sector entities in order to improve the rapid response of public administration entities during epidemics.