The coronavirus health restrictions are now gradually being relaxed. What is the likely scenario for the coming months?
There’s still a high incidence of infections and so we still can’t think about normalising everything. However, it is true that we’ve seen a few weeks of accumulated decline in the epidemic curve. This provides a relatively good outlook for the next few months, unless there is a scare with the appearance of some new variant or with the Omicron subvariant (BA.2) that is circulating mostly in Denmark. But if the indicators continue to improve, we can begin to relax the restrictions.
When will that time come?
When the rate of incidence comes down to the level of 50 cases per 100,000 inhabitants, which is our point of reference for low virus circulation. This would be the moment to return to normal life, albeit with epidemiological surveillance in place in order to allow us to predict ahead of time the threat of any new wave. The forecast is that if the same variant or similar less severe variants continue to circulate, we could be talking about an endemic situation developing: i.e. the virus is there but it circulates in a controlled way and Covid-19 cases can be treated without affecting the treatment of other pathologies.
You talk about the threshold of 50 cases per 100,000. Right now the rate is still much higher than that, so we’re still some way off.
That’s why I don’t favour removing all the health restrictions. When we reach the threshold of 50 cases per 100,000 is when we can consider stopping diagnostic tests on everyone who has symptoms, as well as stop monitoring close contacts, and we can eliminate all quarantines. At the moment we can only consider removing all restrictions in schools, because we know that children are the people who are least vulnerable to the disease; it affects them very slightly and there are almost no hospitalisations among children due to complications with Covid, and so serious cases among children are very exceptional.
Could you see a scenario like in the UK, where the official approach has been to accept that we have to live with Covid just like any other virus?
We still have to wait. I don’t rule out that possibility coming up in a few weeks, as long as all the indicators continue to fall at the current rate.
You chair the scientific advisory committee. What has the Catalan government asked of you?
The government asked us a few weeks ago to present a paper on this transition phase, on how we can live with the virus when the indicators improve and immunity is high enough – we are now above 80% among the general population. We are working on a plan and will present it soon.
You prefer to be cautious?
We think that by far the best idea is to be prudent, to begin to make the measures more flexible in schools, under close supervision, and if all goes well, to then apply it to the general population.
The message used to be that we had to stop transmission of the virus at all costs in order to prevent the emergence of new variants. Now this doesn’t seem so important and we’ve seen record numbers of infections with Omicron. It’s hard to understand.
The change of message is due to the fact that until recently vaccine coverage was not high enough and we had very little information about the virus. Each new wave led to a very high number of hospitalisations and deaths, so restrictive measures had to be taken to prevent the virus from circulating easily and to protect the population with non-pharmacological measures, because at first we had no vaccines or antiviral medicines. Now there are more tools to deal with the virus and it means that after two years of pandemic we do not have to maintain the same level of restrictions, which come with a cost that is not only economic. Every time there’s a new wave, we have to halt transplants, heart surgeries, the care of many other diseases and the early diagnosis of cancer, and we will surely pay a price for this in the coming years. Now, with a large part of our population protected by vaccines and new antiviral treatments arriving, we need to try to live with the virus without applying such restrictive measures. Of course, while also avoiding deaths and focusing efforts on vulnerable people.
The Omicron variant has bypassed immunity and people who were vaccinated or who have had Covid have got the disease again. Some people wonder why they should be vaccinated.
We knew from the start that the Covid vaccines would reduce the chance of infection but not prevent it completely. What they do above all is reduce severe forms of the disease. Omicron has changed everything, and the effectiveness of the vaccines against infection has been low. In addition, it has been found that more than six months after the second dose, the protection decreases to around 70% compared with the initial 90%. That’s why we have insisted on the need to administer the third booster shot. Vaccines won’t prevent us from becoming infected but they can help us avoid serious complications, which is where their importance lies. It’s important for people to get a third dose, and that those who are immunocompromised should be given a fourth dose about five months after the third.
Is Omicron less severe due to the variant itself or the effect of the vaccines?
We now have a lot of information, especially from the UK’s health department, which has analysed the data based on the level of vaccination and concluded that it is due to both factors together.
The death toll is proportional to the number of infections. Shouldn’t we debate what threshold of infections we are willing to accept?
It’s a debate we need to have. In the case of influenza, for example, the threshold we consider to be an epidemic is 90-100 cases per 100,000 inhabitants. Something similar will have to be done in the case of Covid-19, setting thresholds that will sound the alarm and trigger health measures. And the measures will depend on the variant of the virus and its effects; if there’s no significant increase in hospitalisations, less restrictive measures will suffice. However, if a variant causes more serious illness and more hospitalisations, the measures will have to be more drastic. We may have to return to limiting the capacity of certain places or shutting down some services if the healthcare system begins to suffer and the death toll goes up. At the moment, however, this scenario is not expected with Omicron.
It sounds like an uncertain scenario: what may serve us today may not serve us tomorrow.
We need to be clear that the pandemic is not over. Things are getting better and the forecasts suggest that they will continue to get better in the coming months. But everything can change at any time. This virus has already brought surprises with it, and there could be more.
We’ve already heard that the pandemic is on the point of ending several times now.
Communication has not been the best. Pandemic fatigue and the need to hear good news has probably led us to jump the gun at times. When the vaccines first arrived, it seemed that we were already nearing the end. We must be careful not to create false expectations, but it’s clear that the current situation is nothing like what it was a year ago.
People are still dying despite all the indicators improving.
Things are better, but the high number of infections in the latest wave means there have also been more deaths. There’s been a lot of talk lately about Covid becoming like the flu, a comparison I don’t like, and one we heard at the start of the pandemic when it was often said that we were dealing with a kind of flu. But no, Covid is not like the flu; it is a more serious disease. There are between 500 and 1,000 deaths every flu season in Catalonia; in the most recent sixth wave of Covid, we reached 500 deaths in just the first two weeks.
You’ve worked on different programmes aimed at preventing and controlling emerging viruses. From your experience working on the likes of Zika and Ebola, how do you think the pandemic will evolve?
There are three different scenarios. The most immediate, predicts that in the next few months possibly very transmissible but much milder variants of the virus will continue to circulate, causing small waves of infections but without it becoming a seasonal virus, although that could easily change. This is the scenario that the World Health Organisation sees as most likely. Secondly, there is the worst case scenario: that a new variant appears that can bypass the protection of the vaccines in a more drastic way than Omicron has. This could send us back to the beginning. It’s a scenario that is considered unlikely, but we cannot rule it out. And the third scenario – the most optimistic of all – is that with so much of the population vaccinated, the virus disappears, as happened with SARS-CoV- 1 or MERS. However, after two years of pandemic this seems to me highly unlikely. The far more likely scenario is that over the next few years we will see the virus continuing to circulate – probably in a seasonal manner – and it will continue to cause regular epidemic outbreaks and waves of infections that we will have to counter with vaccines and antiviral treatments. The most vulnerable people will need the most protection and will have to be revaccinated. Special attention should be given to these people; they should be diagnosed quickly through PCR testing and then they should be treated early with antiviral medicines to avoid complications.
Will a fourth booster be needed for the general population?
It’s only been a short time since we administered the third booster shot and so we need to see how the immunity evolves. Yet if we continue to deal with the Omicron variant or similar, non-vulnerable people should not be given a fourth dose. In the case of the vulnerable, yes, and in fact that is already being recommended.
Apart from the immunocompromised, who else should be considered as vulnerable?
The list needs to be finalised, but in general we’re talking about immunocompromised patients, people with Down syndrome, elderly people in nursing homes, and hemodialysis patients. Another group that might be included are morbidly obese people, because many Covid patients who ended up in the ICU who had no pathology other than obesity. And we will probably have to establish an age criterion – from 60 or 65 years old – as we do with the flu. With Covid we know that age is a risk factor in itself.
To monitor the virus, epidemiological and genomic surveillance will be important. Will new healthcare structures also have to be established?
The public health system needs strengthening and within the system there should be a public health agency with powerful tools, not just epidemiological surveillance, but integrated systems of case monitoring, such as microbiological surveillance, animal surveillance or wastewater monitoring, as they anticipate the circulation of viruses very well. Genomic sequencing should also be increased, as that way new variants can be detected earlier. And there’s still the whole issue of digitising the case log to give us a real-time picture of what the situation is at any moment so that we can move forward and tackle the problems. All these services need to be restructured, and that’s what we’re working on.
Looking back over the past two years of pandemic, what mistakes need to be corrected?
Taking action late. At times we’ve seen what’s happening in other countries and yet we’ve been very slow to put measures in place. I’m thinking, for example, of when the Delta variant entered the UK and the situation started to get complicated, or when Omicron appeared in , in both cases it took us far too long to implement health measures. Measures need to be taken earlier.