(QCOSTARICA) “As of June 8, 4,628 new cases of COVID-19 are registered, for a total of 79,951 and 800 deaths are reported. There are 33,578 people recovered and 45,563 active cases. In addition, there are 3,958 people hospitalized, of which 792 require intensive care”.
This is the report that the Health Minister, Daniel Salas, would have had to give the country today, Monday, if Costa Rica had not taken measures in time to deal with the pandemic.
Our hospitals would now be collapsed if the authorities had not restricted borders, expanded the vehicle restriction, suspended school, canceled massive activities, as well as closing bars, restaurants, discos, casinos, parks, beaches and religious temples.
The new SARS-CoV-2 virus simply would have followed its natural course before a population immunologically defenseless to its action.
According to an analysis prepared for La Nación by a group of specialists, the country would have almost 80,000 registered COVID-19 infections today and the intensive care beds would have been full as of May 18.
Such estimates greatly contrast with the latest official figure: 1,318 cases this Sunday, 20 people hospitalized (four of them in intensive care), and 10 deaths.
If the pandemic virus had followed its natural course it would have taken less than a month to reach a thousand cases, and the month of June would end with almost 250,000 cases
The mathematical projection was carried out by the Center for Research in Pure and Applied Mathematics and the School of Mathematics, both from the University of Costa Rica (UCR); the EpiMEC research team (Epidemics, Mathematical Modeling, Statistics and Computing); the Pan American Health Organization (PAHO) and the Ministry of Health.
Their analysis estimated the number of cumulative cases, active cases, recovered persons, and hospitalized persons that would have occurred if actions had not been taken in time.
The number of people in intensive care, meanwhile, was calculated based on the information given by Román Macaya, executive president of the Costa Rican Social Security Fund (CCSS), who has indicated that 20% of hospitalized people have required to connect to a respirator.
Meanwhile, the number of deaths is calculated taking as a reference to the percentage of deaths (1%) that has been observed so far in the national territory.
This type of modeling helps to put into perspective the action of an unknown and highly transmitted virus in a dynamic population, which is mobile and has contact with other people, all of whom are susceptible to contracting the disease.
According to the mathematical model, the virus would not have entered the country on March 6; rather two days earlier, on March 4. And, instead of registering only two cases that first day, the number would have been 17.
Despite the fact that the vast majority of people would have mild symptoms, on May 18 the hospitals would have been left without a bed of the 1,088 available beds to receive COVID-19 patients and a day later all 257 beds of the intensive care units (ICU) would have been occupied.
The projection indicates that on April 24, a first warning sign of the spread of the virus would have been seen, since it is estimated that on that day there could have been 50 cases in intensive care.
“The behavior of the pandemic in Costa Rica has forced the beds to be managed differently, although by the time all those 1,088 are used, more than 46 ICUs would already be an alarming indicator that the system is collapsing (… ). We hope we don’t get to that scenario,” said Mario Ruiz, medical manager of the CCSS.
It is also estimated that by June 15, the 5,525 hospital beds available in all hospitals in the country would have been insufficient to deal with all the sick.
For July 7, the last day that the estimates cover, 9,579 new cases and a total of 306,980 accumulated cases would be registered. That day, 13,423 people would have needed to be hospitalized and 2,685 of them would have needed intensive care.
In addition, if the trend in the percentage of deaths had been maintained, by that time there would be 3,070.
However, this number of deaths would be unlikely, given that with health systems collapsed since May, not all people would have had access to the services they needed to stay alive or with consequences for their health or well-being.
“If nothing had been done, there would have been a huge excess of cases. We cannot speak only of pure mathematics, because human interaction is much more complex than that; We would have more (sick) people than we imagine.” said epidemiologist Ronald Evans.
“The Tica (Costa Rican) advantage is that they took things seriously and the first steps were very fast. There were those who underestimated the restrictions and see, for example, where Brazil is now!”, he added.
His colleague, former Deputy Minister Ana Cecilia Morice stressed that these numbers, although they are projections and it will never be known how that reality would have been, they do help to dimension not only how the virus acts, but also the effectiveness of the decisions taken.
“It is important to see that what we did as a country did bear fruit, yes, deaths were avoided. Not only the decisions of hierarchies, but also the actions of citizens. Given the uncertainty, measures had to be taken with the evidence that is available at all times,” said Morice.
Where do these projections come from?
Fabio Sánchez, leading mathematician of the scientific team in charge of numerical modeling, explained that these data are in a model called networks, which is based on the conditions of the human being to have daily contact with different groups of people.
Furthermore, the model is adapted to the demographic conditions of the country and the characteristics of the virus.
“In the event that no action had been taken, this models the epidemiological process where each person has a number of family contacts, friends, and coworkers and that there is a probability of contagion if there is an infected person.
“So the disease is growing and as there are no measures, it simply grows exponentially and without control and that is why we see that number of cases,” Sánchez said.
“People are divided into epidemiological states. There are susceptibles; people who are with the disease, but with a degree of incubation; hospitalized; and recovered. Each one, according to their condition, will interact with people in their different social circles,” he added.
The model begins to plot data from February 26, the day that the pandemic virus reached Latin America, when it was found in a Brazilian man.
To these data, it was added that in the country there are 257 intensive care beds (which are not exclusive for covid-19), plus 1,000 beds for pandemic disease in the different hospitals and the 88 beds of the Specialized Care Center for Covid (CEACO).
Taking into account is that the country has 740 respirators
Characteristics of Costa Rica mark behavior
To understand the projections on the impact of the COVID-19, it must first be taken into account that Costa Rica never had an extreme quarantine.
Measures were taken to stop the transmission of the virus and recommendations were made to stay home and go out only if necessary and, subsequently, in a social bubble. Unlike other countries, there was no regulation that forced people not to go out.
Other characteristics such as the country’s small population and low population density compared to other nations are also factors that add up.
“It is important to emphasize that in our country there has been no sustained transmission, but rather a behavior in clusters (conglomerates of cases) and this requires a very meticulous follow-up of contacts,” explained former Deputy Minister Morice.
“That is why the numbers rise and fall, because they depend on the characteristics of the clusters, on the timeliness of the response and the effectiveness of the contact blockade. In other words, decisions are not only made on the case curve, but rather by taking take other indicators into account,” she asserted.
Another point to be made clear is that sanitary restrictions were never intended to eliminate the pandemic virus. Once it entered the country, given its high level of contagion and that the population had no defenses whatsoever, it was impossible for transmission to stop completely.
“To this, we must add the population of asymptomatic or very mild cases that spread and spread to other people without being detected,” Morice said.
“We always talk about the need to flatten the curve, but this is not to avoid contagions at all, it is so that the health services can give an effective response and thus avoid deaths,” she added.
The specialist stressed that another point in favor of Costa Rica is that by the time the pandemic arrived, the experience of other nations was already known and learned from.
An additional positive factor is the low percentage of hospitalization of the sick. While the world average of patients requiring admission to a medical center is 20%, in Costa Rica it has not exceeded 10%.
“We still don’t know why the difference is. It may be due to early detection, treatment, genetics of people (…), but it is not yet known for sure,” said Mario Ruiz, medical manager of the CCSS.
‘New normality’: Scenarios mark that it must be gradual
On April 27, when the possible scenarios for the evolution of the pandemic in the country were presented, the Minister of Health, Daniel Salas, released a forceful warning phrase: “If all restrictions are lifted today, we would have 53,000 cases a mid-July”.
Salas released a projection that day based on the continuation of the measures in force at that time, that is, without reopening. It was estimated that, as of July 21, there would be 1,368 cases. However, the country is very close to reaching that figure today, with a month and a half to go until the expected date.
In fact, this Monday the number of confirmed infections rose to 1,342 with the addition of 24 new cases.
One of the possible reasons to explain this increase in cases is that the current measures are not as rigorous as those that were in place on April 27.
For Ana Cecilia Morice, the behavior of the daily numbers and the projections is proof that the restrictions must be lifted very gradually and remain in constant evaluation.
“It is not about shutting ourselves in the house, but to see the characteristics of each activity and the risk of contagion,” said the specialist.
For Morice, the opening of activities must depend on four factors:
1- Level of virus transmission in the country and according to geographical areas. This is something that has already been seen in the most recent analyzes of the Ministry of Health, where each canton is categorized in white, green, yellow, red, according to the number of active cases.
2- Individual risk of people and the possibility of reducing severity and lethality.
3- Risk of economic activity and the possibility of modifying it to reduce risk.
4- Social value of the activity and collateral damage when suspending it.
“We must adapt to living with the virus, but the return to normal should be little by little and constantly reviewed. It has to do with social conditions, but also economic. The evaluation of each step and seeing the results is essential,” Morice concluded.