Pressure from hospitals to tighten restrictions and contain fourth wave

In the Hospital de Sant Pau in Barcelona, like all health centers in the country, they have worked at full capacity during the Easter holidays. In this case, also in network with other health care services to start referring patients in anticipation of a rise in admissions for coronavirus that can lead to the limit of intensive care services. "We are concerned because we expect, at least, a scenario similar to the third wave and everything suggests that we will have an increase in ICU admissions which will strain the rest of the priority activity", explains Mireia Puig, head of the emergency department at Sant Pau. In fact, most health professionals consulted by the ARA already take for granted that from next week on they will have to once again start to unschedule non-covid hospital activity. And to avoid this, they stress, we must contain the virus, the sooner the better. In the absence of a good rate of vaccination coverage among the most vulnerable population, they all say that the only tool available is the tightening of restrictions.

From 600 patients admitted to the ICU on, "the health system is jeopardised because it means that you already have half of the units occupied with covid patients, and you have to stop other interventions that also require critical beds", warns the director of preventive medicine and epidemiology of the Vall d'Hebron, Magda Campins. To once again take the decision to postpone and reschedule surgeries and outpatient consultations would be very detrimental to the health of the population. "All hospitals are already overloaded and there are many other diseases to attend. We are concerned about all this because to reach a situation similar to that of the first wave would be a huge and catastrophic damage", corroborates Josep Maria Mòdol, medical director of the Germans Trias i Pujol Hospital.

Mòdol anticipates that in the next few weeks the peak achieved in the third wave may be reached, "despite being in full growth" of the fourth wave. All this, agree the healthcare professionals, without yet knowing the effects of the mobility of Easter, so that if it translates into an increase in infections, as is foreseeable, the number of patients admitted to the ICU could exceed 700, as predicted by Jesús Caballero, president of the Catalan Society of Intensive and Critical Care Medicine (Socmic) and director of the intensive care medicine service at the Arnau de Vilanova University Hospital in Lleida.

Hospitals still expect between two to four weeks of increased hospital pressure. Moreover, they have not ruled out that this wave might equal the number of admissions to ICUs of the first wave, when there were 1,300 occupied beds, 900 by covid patients. Unlike the first and second waves, however, now the health system is more prepared, there are more treatment options and more protective measures. "Even so, one possibility that arises is that this fourth wave has the same impact [in number of admissions to the ICU] as the first one had or, if you want to put it another way, has more impact than the second and third", argues the director of the service of preventive medicine and epidemiology of the Hospital Clínic, Antoni Trilla.

70% of the population can be infected

However, the real impact of this fourth wave -or rebound of the third, according to Trilla- "will be modulated by the restrictive measures taken", says Clara Prats, researcher of the Biocomsc group, who believes that the regional lockdown will be insufficient to control the advance of the pandemic. Broadly speaking, 70% of the population "is still susceptible to infection because they have not been vaccinated or have not passed the disease and the British variant, which is fast and aggressive, still has a long way to go", says Trilla.

The heads of hospital services consulted by the ARA believe that the only way to curb the fourth wave is to tighten restrictions, since the effects of vaccination will not be here in time to contain it. The effect of vaccination is noted on mortality -many of those over 80 years have already been vaccinated with the first dose and virtually all users of care homes are protected-, and a little in conventional hospitalization. For the moment, however, the vaccines are not curbing admissions to ICUs. "Vaccination is insufficient in the age groups entering the ICU. This wave will not stop with vaccination, we already have it here and the only way is to increase the level of restrictions", says Mòdol, from the Germans Trias i Pujol Hospital, who believes that "more aggressive restrictions" are needed and calls for a "last effort" before achieving herd immunity.

"An acceleration in admissions in ICUs is already a bad indicator to take decisions, it means that we are late: the infections have already occurred 10 or 15 days before and admissions will continue to rise for at least 15 days", warns Jesus Caballero, who recalls that the benefits of regional lockdown will not be seen for another fifteen days. He is also in favor of tightening the measures to give time to vaccinate the most vulnerable groups, those older than 65, and is committed to "shorter and more severe" restrictions to cut community transmission. "Procicat decisions are painful because of the economic and social impact, but lives are at risk. As an intensivist, I would tighten the measures even more. But for now it has been decided to maintain the easing of restrictions and that the health system keeps holding on", he says.

Easter effects

The effects of Easter mobility also remain to be seen. The current data of contagions are not reliable, since the effect of the holidays have made fewer diagnoses: people have not gone to hospitals or primary care centres despite having symptoms unless they were very ill. Beyond the images of queues on the roads and crowded beaches, what worries health authorities and health professionals is what was not seen: what happened inside homes and in closed environments. If cohabitation bubbles have mixed and protective measures have relaxed, they say, the British variant will have had a window of opportunity to generate larger outbreaks and increased admissions to critical care units.

"We deny reality time after time", laments José Luis Lopera, head of the ICU of the Consorci Hospitalari de Vic. "It happened in the first wave with China and Italy, when calls for draconian decisions were made and not heeded. Then it happened with the United Kingdom: in London one in twenty citizens was infected with the British variant but this collapse of care was seen as if this could not reach us. So we began to relax measures, contagions grew and now the curve will skyrocket. We could see it coming", concludes the intensivist.