A healthcare provider performs a PCR test in a Health Center in Ejea de los Caballeros (Zaragoza). Javier Cebollada / EFE
Spain is facing its first winter in which two potentially lethal respiratory viruses will circulate.
The scourge of the coronavirus will be added to the end of the flu, a disease that affects almost 800,000 inhabitants each year, sends 52,000 to the hospital and kills about 15,000.
The flu has a faster cycle than the covid.
The season usually begins in the last weeks of December and lasts for about eight weeks.
The main concern is that this epidemic peak coincides with that of the coronavirus, which could cause a double saturation of hospitals.
However, according to the majority of experts consulted by this newspaper, there are reasons to think that the situation will be under control.
“Everything we have experienced so far has been like training;
this winter we face the final test, ”explains doctor Jesús Castilla, member of the national influenza surveillance group and spokesman for the Spanish Epidemiology Society.
The good news is that the health system knows the coronavirus better and better.
The flu is an old acquaintance against which there is also a vaccine.
The bad news is that during the flu peak each year the emergency room collapses in some hospitals, with patients on stretchers in the corridors.
This situation may be aggravated by the lack of beds that are expected to be occupied by covid patients.
According to Castilla, the key is to prevent contagion as much as possible and, for this, it may be necessary to further restrict movements in the most affected areas during the months with the highest flu incidence, starting in January.
"We will have to find the perfect balance trying to ensure that the activity is the maximum possible but minimizing risks," he says.
One of the biggest unknowns is the interaction of the coronavirus and the flu.
Hardly anything is known about it.
The few data available show that it is possible for a person to carry both viruses at the same time, as doctors in Spain and other countries have recorded.
However, it seems that these double detections are not very frequent.
More worrying for doctors will be successive infections.
Both viruses attack the respiratory system.
The first line of defense of the immune system can be weakened after a first infection.
"A viral infection is a major stress for the immune system and then it is weakened, with which the probability of becoming infected with another increases and possibly also the severity of this second infection", explains Carmen Cámara, spokesperson for the Spanish Immunology Society .
“Everything we have experienced so far has been like training;
this winter we face the final test "
Jesús Castilla, epidemiologist
"For now we do not know if the coronavirus influences the progress of the flu infection or vice versa, although it would not be expected," explains Ángel Asensio, head of preventive medicine at the Puerta de Hierro Hospital in Madrid.
"The goal of everyone, of any age, should be to avoid one or another infection and for this the best thing is that they behave as if they were already infected but without symptoms, that is, that they isolate themselves, wear a mask, have a hygiene extreme and even get vaccinated against the flu even though they are not at risk population ”, he points out.
One of the biggest challenges for the health system will be distinguishing which patients have coronavirus and which others have the flu.
Both viruses produce very similar symptoms, although it is possible to differentiate them, according to Cámara.
"The flu generates a lot of mucus and the coronavirus nothing," he explains. There is also the loss of smell and taste, a symptom described in a separate part of covid patients that has not been observed in cases of flu, he adds.
But the final proof will be provided by the tests.
The usual way to make a sure diagnosis is using PCR.
This is going to be a problem because the covid is monopolizing a large part of the analysis capacity of hospitals, recognizes Lola Folgueira, virologist at the Hospital 12 de Octubre in Madrid, one of the Spanish health centers with the most covid patients.
"It is clear that this winter there will be additional pressure on the diagnostic laboratories of hospitals," explains the doctor, who is also in the national influenza surveillance group.
"One of the problems we had with the first wave of coronavirus was that we needed a lot of reagents [chemical compounds to carry out a PCR] and companies could not cover so much demand, something that could be repeated now," she explains.
But even in a hospital like yours, the forecasts are not alarming.
“It is very difficult to know what is going to happen.
The feeling is that the cases of covid with hospital admission are increasing, but not exponentially as we saw in the worst months of the pandemic.
On the other hand, our forecast is that the incidence of influenza will be lower than in other years.
This leads us to think that we could spend this autumn and winter reaching our occupancy and attention limit, but without a collapse like the one we have already seen ”, he says.
Making a correct diagnosis can be the difference between a life saved or lost.
For now, the only drug that has proven efficacy against COVID is dexamethasone, which reduces mortality in critically ill patients by a third thanks to its anti-inflammatory properties that calm the overreaction of the immune system of some infected.
But this and other corticosteroid drugs can be very harmful to a person with the flu.
To aid in diagnosis without the need for PCR, rapid antigen tests are available this year that work in a similar way to pregnancy tests.
Making a correct diagnosis can be the difference between a life saved or lost.
In fall and winter, many other viruses circulate that cause colds and respiratory illnesses that can further muddy diagnosis and treatment.
They are enterovirus, rhinovirus, cold coronavirus.
Among them, the respiratory syncytial virus stands out, whose epidemic peak occurs in late October or early November.
It is especially dangerous for babies and young children and in some years it can cause a collapse of pediatric emergencies.
It can also be dangerous for people of advanced age or with previous pathologies, that is, the group most vulnerable to covid and flu.
The biggest problem that these viruses will bring is that tests are not normally done to check which virus is infecting the patient, explains Pasi Penttinen, head of the influenza and respiratory virus program at the European Center for Disease Control.
“The only way to confirm the diagnosis to know if the patient has one of these viruses or on the contrary suffers from covid is by using PCR and this will pose a great dilemma for hospitals, since many will have a good part of their laboratories already compromised by covid tests ”, he acknowledges.
Right now the eyes of all doctors are on the southern hemisphere, where there is very good news.
Winter is almost over there.
Several countries have registered far fewer flu cases than other years.
A spectacular case is that of Australia, where 10 times fewer cases have been diagnosed this year than the previous one.
The main reason is that both the coronavirus and the flu are transmitted by close contact and this has undoubtedly been one of the least contact winters in recent history.
Border closures, lockdowns, and the widespread use of masks have likely halted the advance of both viruses.
Most of the experts consulted believe that something very similar is going to happen now in the northern hemisphere, including Spain.
The flu vaccine will be the best weapon to avoid unnecessary deaths
“During the worst of the pandemic, only the most serious cases reached the hospital, it was only the tip of the iceberg.
If we saw 3,000 cases, that meant that in reality there would be about 30,000 undetected ”, explains Carmen Cámara, who works at the La Paz Hospital in Madrid.
“Now we have gone under the water and we see what there is;
We do many more tests, so if we see 3,000 cases it means that outside and undetected there may be only about 6,000 ”, he exemplifies.
Now more than ever, vaccines will be the best weapon to avoid unnecessary deaths.
In the coming weeks, the group of European experts on vaccines will meet and they will re-analyze the situation and make a recommendation on whether to broaden the criteria for influenza vaccination this year.
The vaccination criteria depend on each country.
In Spain the flu vaccine is recommended for those over 65 and chronically ill.
In other countries such as the United Kingdom or Finland, children are also included, explains Penttinen.
“Unlike the covid, children are the main spreader of the flu every year.
By vaccinating them, you generate group immunity and prevent them from infecting the elderly and risk groups.
It is clear that going back to school in European countries will be a key factor in the spread of the flu, but this year it is much more important to vaccinate health personnel, the more the merrier.
They are the ones in direct contact with the groups at greatest risk of covid, flu and the rest of the viruses that will arrive in a few weeks, ”he concludes.
In Spain, the Government has increased the purchase of doses to five million with the aim of protecting 75% of the elderly - the level recommended by the European Union - and risk groups, such as patients of all ages with diseases chronic or with a very weakened immune system.
This will be a battle of awareness rather than availability of doses.
In 2017, only 54% of those over 65 were vaccinated.
And this percentage is very good when compared to that of health personnel, one of the most exposed to the virus, and who only reached 35%.
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