How Spain wants to lead global shift in Covid-19 surveillance

With governments and populations worldwide desperate for an end to the pandemic, talks over when the virus might be reclassified have intensified. Spain has stepped up and wants to lead an international push for Covid-19 to be monitored in a similar way to seasonal flu.

spain covid surveillance
A healthcare worker tends to a Covid-19 patient in the ICU in Barcelona. Spain has seen a surge in Covid-19 infections since December and prevalence is currently among the highest in Europe. (Photo by Josep LAGO / AFP)

“Spain wants to lead this debate because it is timely and necessary to do so,” Health Minister Carolina Darias has said, adding that Spain asked the European Centre for Disease Prevention (ECDC) to “study new strategies” to deal with Covid.

Spain is in a good position to open the debate, having one of the world’s highest vaccination rates with 90.5 per cent of its population over the age of 12 fully immunised.

But the question has sparked disagreement between governments seeking some sort of normality and some parts of the medical community which advocate keeping its guard up.

READ MORE: Spain’s health experts divided over whether Covid-19 should be treated like flu

Spain’s left-wing government has been a prominent advocate of reclassifying Covid as an endemic disease with milder seasonal outbreaks that humanity can live with, like the flu.

The country is working with the scientific community to eventually shift from “managing a pandemic to managing a disease which we hope science will reclassify as an endemic illness”, Spanish Prime Minister Pedro Sanchez said this week.

Although Omicron has triggered a surge in infections, there have been fewer deaths and lower rates of hospital admissions, with many governments easing restrictions, reducing isolation times and loosening border controls.

“As Covid becomes endemic, we will need to replace legal requirements with advice and guidance,” British Prime Minister Boris Johnson said Wednesday, announcing that restrictions were being lifted in England.

Arguing “we must learn to live with Covid” in a similar way to seasonal flu, British Health Secretary Sajid Javid said the government would set out a long-term plan for living with coronavirus within months.


‘False hope’

On Tuesday, however, World Health Organization chief Tedros Adhanom Ghebreyesus insisted that the pandemic was “nowhere near over”, warning that new variants were still “likely to emerge”.

The UN health organisation also warned against the temptation to play down the seriousness of an endemic disease.

“Endemic in itself does not mean good — endemic just means it’s here forever,” the WHO’s emergencies director, Michael Ryan, told the Davos Agenda roundtable on vaccine equity, citing malaria as an example.

Fernando García, an epidemiologist and the spokesman of a public health association, warned that talk of treating Covid-19 as an endemic illness at this stage was “creating false hope”.

“We are indeed moving towards the virus becoming more endemic, but we cannot say we have already reached that status,” said Marco Cavaleri, head of the European Medicines Agency’s (EMA) vaccination strategy.

There is no numerical threshold that distinguishes between an epidemic and a disease which is endemic, Garcia told AFP.

“An epidemic is when there is a very significant outbreak of cases, above the normal, which is what we have experienced since the beginning of 2020,” he said.

“And endemic diseases may have a seasonal trend but do not put pressure on the health system.”

Nor is it a foregone conclusion that the virus will evolve to cause less harm.

‘Mild symptoms’

“Future severity remains a big unknown. There is no law dictating that a virus must become milder over time,” Antoine Flahault, director of Geneva’s Institute of Global Health, wrote on Twitter.

“It is very hard to predict the evolution of virulence.”

When Covid-19 becomes endemic, “most people who become infected will have mild symptoms”, Garcia said.

“There will be a few who suffer complications that mean they end up in hospital and die,” he added.

“But you’ll never see one in four intensive care beds occupied by Covid-19 patients, not even five percent of them. Cases will probably be handled by primary care.”

In Spain, more than 23 percent of intensive care beds are taken up by Covid patients and more than 91,000 people have died since the pandemic first took hold in March 2020.

Of that number, 2,610 died between December 17 and January 18.

Some healthcare professionals have backed the Spanish government’s approach.

“Let’s stop visiting and testing healthy people with mild symptoms, or tracking and testing their contacts, let’s abandon self-isolation and quarantine,” urged a recent article by SemFYC, which represents around 19,000 family medicine specialists.

“All these activities… have been rendered meaningless with acquired immunity (both through infection and through vaccination) and the arrival of Omicron,” it said.

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Face masks to remain mandatory on public transport in Spain until March 2023

The Spanish government's health experts have agreed not to review face mask usage on public transport until March 2023, a new report has found, by which stage almost a whole year will have passed since other face mask rules were lifted.

Face masks to remain mandatory on public transport in Spain until March 2023

Although masks haven’t been mandatory in indoor public settings (except hospitals, pharmacies, care homes and other health-related centres) since April 20th 2022, face coverings must still be worn on public transport in Spain, such as on buses, planes, taxis, metro carriages and trains.

According to a report published in Spanish news site Voz Populi, Spain’s Emergency Unit has agreed not to review Spain’s face mask rules until March 2023, even though all other Covid-19 domestic and travel restrictions were lifted before the summer of 2022.

The article, which cites internal sources from Spain’s government, adds that the country’s Public Health Commission (a body which advises Spain’s Health Ministry on which measures to introduce) has reportedly agreed to shelve any possible changes until March, and as things stand keep the rule in place “for an indefinite time” as “it is not the right time to remove masks due to the arrival of winter”.

The Health Ministry, however, argues that no fixed date for reviewing face mask legislation has been set.

“We’re taking the German approach,” the Emergency Unit source told Voz Populi about the fact that Germany is the only other country in Europe with similar mask-wearing rules to Spain.

On October 1st, new measures were brought into force in Germany stating that passengers over the age of 14 must wear FFP2 masks on long-distance trains rather than surgical ones, with the German government saying it will not review the legislation until April 2023.

Fernando Simón, Spain’s Health Emergencies chief, told journalists recently that “it’s okay to wait a little bit to see how the disease evolves” before making a decision regarding the complete removal of face masks.

However, if Spanish health experts are indeed looking to follow in the footsteps of Germany, there is even a possibility that the return of face masks to all indoor public settings this winter could happen, or at least a debate about it. 

An increase in Covid and flu cases that’s overburdened hospitals this autumn, as well as the emergence of the new Omicron subvariant BQ.1, has resulted in German authorities considering whether they should bring back old Covid-19 restrictions for the winter months.

Spain is also starting to see an increase in Covid and flu infections, and talk of an eighth coronavirus wave is rumbling in the background, but there has been no mention yet by Health Ministry representatives of a possible return to indoor face mask wearing across the board.