At the start of the year, Portugal was experiencing a very high rate of covid-19, three authors reflect on what lessons need to be learnt to prevent another wave
On 28 January 2021, Portugal’s incidence of new cases of covid-19 per million people stood at 1264/100,000 inhabitants—the highest rate in the world at the time. By then, hospitals were overwhelmed and started transferring patients to other hospitals with available beds, including field hospitals. Hospitals in the region of Lisbon and Tagus Valley struggled the most, with reports of long lines of ambulances queueing to drop off patients in emergency departments. A field hospital was set up across the street from Lisbon’s largest hospital, Santa Maria University Hospital, and other European countries, such as Germany, France, and Luxembourg, sent hospital teams. The nationwide death rate in January was sobering and followed a long period of excess mortality starting in October 2020. By 31 December 2020 Portugal had accrued 6906 covid-19 deaths since the start of the pandemic, at the beginning of March the count had gone beyond 16,000.
In primary care, routine activity was affected considerably, with most staff allocated to contact tracing and remote monitoring of suspected and confirmed covid-19 patients recovering at home. Many GPs were deployed to outpatient covid assessment centres.
In early February the scenario was improving, roughly two weeks after the second hard lockdown in one year. On 15 March 2021, the reopening process began, with schools reopening up to primary school level and some limited commercial businesses—such as bookshops and hairdressers—being allowed to open their doors again.
So how and why did Portugal get to this point? The third wave started shortly after Christmas. Portugal was one of the few European countries where most restrictions were lifted during the holiday period, and the guidance for the public, in terms of what people should be allowed to do, was not effective. The third wave also fell into a period where numbers of covid-19 patients in hospitals were still very high and the country was still barely recovering from the second wave (October-December) with some 3000 admitted patients, including 500 in intensive care units. The increasing presence of the UK variant B.1.1.7 also probably had a role in accelerating transmission. No additional mitigation measures were taken after the holiday season.
What matters most now is to make sure that we don’t experience another devastating new wave. A lot of hope rests on the vaccination programme, but like as in other European countries, coverage is slow because of a vaccine shortage.
The government rallied from the January events and implemented a new risk approach. The transmission rate (Rt) and the incidence rate were combined in a matrix. Should the Rt rise above 1 or the incidence rise above 120 new cases (of infection) per day per 100,000 inhabitants in 14 days, restrictions need to be expanded and vice versa. The availability of intensive care beds is also considered when making decisions on reopening.
Efforts have been made to expand testing and a risk communication task force was assembled to respond to one of the main criticisms namely, that of poor communication from the authorities throughout the pandemic.
This pandemic uncovered weaknesses of Portugal’s national health service that have been only partially mitigated, and it is crucial to learn the lessons from this pandemic. A new pandemic is bound to happen and the healthcare system has to be prepared; we have to take care of patients infected with SARS-CoV-2, but care for other patients must be preserved. The hospital design must be scalable, convertible, and promote safety. We have to secure a reserve of essential equipment to respond to a fourth wave or to another pandemic; we cannot continue to reduce the number of hospital beds, and a sufficiently high number of intensive care beds must be provided. IT systems and telemedicine should be boosted; the current vertical model of hospital is inadequate, and a matrix organisation must be implemented. We need new organisational models, such as specific units for certain conditions, co-management, and hospital-at-home and case management programmes. The shortage of healthcare staff compromised the ability to respond to this pandemic and must be built up. Internists were at the forefront of fighting this pandemic in Portugal and, with their versatility and generalist training, showed the importance of internal medicine as a core specialty in the hospital; numbers of internists should be grown as care cannot continue to be fragmented, and integrated care, including social care, must be promoted.
Despite all of this, our National Health Service has shown a high capacity for resilience and its professionals demonstrated remarkable dedication and competence. Inequalities in the outcomes of this pandemic were much more serious in countries without a strong public health service, free and with universal access.
Hospitals and GP practices have now resumed much of their previous routine activity. While most European countries are now bracing themselves for a third wave, the incidence of covid-19 in Portugal continues to fall. We are well aware that things can change very quickly, but we have reason to believe that the worst is already behind us. However, we must learn the lessons of this pandemic and have the will and the courage to change.
Tiago Villanueva is a GP in the Portuguese national health service and vice president, European Union of General Practitioners/Family Physicians (UEMO). He is also associate editor, The BMJ and BMJ Open, and editor in chief, Acta Médica Portuguesa. He has no competing interests to declare.
Bernardo Gomes is a public health doctor in the north health region of Portugal. He is also an associate editor of Acta Médica Portuguesa and an invited lecturer at the Faculty of Medicine of University of Porto. He was part of one of the groups that presented risk approach strategies to the Portuguese government. He has no competing interests to declare.
Luís Campos is an internist, director of the internal medicine department of Saint Francis Xavier Hospital, in Lisbon; adviser to the Portuguese Directorate General of Health; chairman of the subcommittee on professional issues and quality of care of the European Federation of Internal Medicine (EFIM), and invited professor of NOVA Medical School. He was previously president of the Portuguese Society of Internal Medicine, president of the National Council for Quality in Healthcare, national coordinator of the Electronic Health Record, and director of the emergency department of the Western Area of Lisbon. He has no competing interests to declare.