(QCOSTARICA) The notorious increase in positive cases of covid-19 in Costa Rica has once again put on alert a country that until now has been a world example of how to manage the pandemic.
With agile and strong measures, taken when there were 41 cases and zero deaths; With a centralized health system that works together with the Costa Rican Social Security Fund (CCSS), the contagion curve was flattened to the point that in the week of Monday, April 20 through Sunday, April 26, there were only 35 new cases.
However, in the first 5 days of June alone, Costa Rica has registered 172 new cases. What is the reason for this significant increase in infections? Does it mean that there is community transmission like in Nicaragua and Panama?
The World Health Organization (WHO) categorizes the state of the pandemic in countries in four phases:
Phase 1: There are no infected people in the country, but the authorities are encouraged to take preventive measures and the population is prepared for the arrival of cases.
Phase 2: The disease doesn’t spread locally. Cases reported are usually people who have had a travel history to an already affected country. That is, they are imported cases; infected people, foreigners or residents who have traveled, who enter the country by land, air or sea, from other countries where there is already circulation of the new coronavirus.
Phase 3: There are ‘clusters’ or contagion groups, but it is possible to identify and isolate them. The country manages clusters of people with COVID-19 who share a geographic location and a common exposure. In order to control this phase and prevent it from moving to phase four, authorities must work quickly to isolate and test COVID-19 on all the people who had or could have contact with the people of these ‘clusters’. There is talk of local transmission, but about 90% of the origin of all cases is known.
Phase 4: Community transmission. There are much larger outbreaks of transmission within the country, and authorities lose track of the chain of infections. There is constant and sustained transmission. The percentage of cases of known origin decreases, and COVID-19 expands throughout the country. The last risk is the possible saturation of health systems.
Officially, Costa Rica is in Phase 3 as described by the WHO. At the press conference this Friday, June 5, Rodrigo Marín, director of Health Surveillance, said: “We guarantee that we do not have community transmission.” And he explained that authorities maintain an active search for cases and the tracking of the chain of infections.
Marín was emphatic but concise. He did not give many details.
Despite this, the Minister of Health, Daniel Salas, has already warned in the past that although there is no evidence that Costa Rica is in phase 4, it cannot be ruled out that there is a “silent community transmission”.
The country in the world that has performed the most COVID-19 tests on its population is Iceland. Until June 5, that country obtained 62,230 samples for analysis. This is 17% of its total population, which is just 364,000 inhabitants.
One of the most relevant lessons Iceland can teach the world is that half of its COVID-19 positive cases had no symptoms. That is, if this scenario with 50% asymptomatic patients is replicated throughout the world, it is possible that you and I have had and passed the COVID-19 without noticing it. And without looking for help in the health services, beyond the normal medicines to treat the flu or a cold.
María Luisa Ávila, a pediatric infectologist and former Minister of Health of Costa Rica from 2006 and 2011, stresses that community transmission is a phenomenon that will come “sooner or later” to the country.
“It may be that we can handle it slowly,” explains Ávila. “There may already be a silent transmission in the community. As this is a virus that in most cases does not produce as many symptoms, and the symptoms are so varied, it may be that cases are already occurring. But here the important thing is to see the number and the increase in the cases that are presented daily. And in the percentage of positive samples. Because that allows us to know what percentage of the population is eventually being exposed or not.”
As of June 5, 2020, the percentage of tests that result positive with COVID-19 in Costa Rica is only 5.8%. In this data, the figure has been reduced, since, in mid-April, the percentage of tests that resulted positive was 8.9%.
Panama, with a population of 4.3 million, has accumulated 1,581 new cases of COVID-19 in the first 4 days of June. As of today, June 6, Panama has 15,463 confirmed cases and 370, as compared to Costa Rica’s 1,228 cases and 10 deaths in a population of 5 million.
Panama and Nicaragua
Costa Rica is between two countries that are already in phase 4 of the pandemic, with community transmission. Panama is an example of what can be done to try to control this phase, while Nicaragua is an example of regrettable management, which represents a mortal danger to its people.
Panama, with a capital that is the world’s air and sea connector, registered its first case on March 9 last. It was a 64-year-old man who had died on March 8 by COVID-19. In other words, the virus had been circulating in the country for days without being detected by health authorities.
To manage the crisis, Panama imposed curfews from 5:00 am to 5:00 pm, a general strict quarantine was imposed, air, sea, and land borders were closed for civilians, all schools were closed, massive events were prohibited, and little by little, economic reopening protocols are also planned.
In Nicaragua, the government of Daniel Ortega and Rosario Murillo chose to do nothing, basically. There was a house-to-house visit campaign to distribute leaflets promoting handwashing, but to date, no national health alert has been declared, nor has any type of confinement or quarantine been instituted in the country.
People are taking measures voluntarily, closely following the evolution of the disease in other latitudes.
In fact, in Nicaragua, the government even fires renowned infectious diseases doctors for criticizing the situation in public hospitals, which are usually run by Sandinista political secretaries and not by doctors.
Nicaragua officially reports 1,118 cases of COVID-19 and 46 deaths. For two months, the government only recognized 25 total cases. Then, starting in May, the government, following the reappearance of its dictator, Daniel Ortega, after not being seen publicly for a month, started releasing weekly information on the evolution of cases.
It went from 25 cases to 279; from 279 to 759; from 759 to 1,118. The numbers reported by Nicaragua’s Ministry of Health (Minsa) were confusing and contradictory. For example, while the official number of positive cases was 25, the Minsa reported more than 250 recovered patients.
Until May, the country has only a handful of deaths from COVID-19, but staggering deaths due to “pneumonia”.
The official contagion “curve” in Nicaragua is this:
Express burials (from dead straight from hospital to cemetery) are a common occurrence in Nicaragua, and the capacity of many public hospitals is known to be overwhelmed.
The NGO Observatorio Cuidadano (Citizen’s Observatory) estimates the number of infections to be in the thousands, more than 5 to 7 times the official numbers and deaths in the hundreds.
Measures in case of phase 4
The former Minister of Health of Costa Rica, María Luisa Ávila, indicates that in case of experiencing phase 4, Costa Rica should follow the same measures that it has developed so far, but they should be followed with more discipline. “Self-management” is also necessary.
“The measures to be taken are the same as those taken. This is where risk self-management comes into play ”, values Dr. Ávila.
“If you are a person with risk factors, if you are a smoker, if you are obese, if you are a certain age and have a chronic disease, then try to take better care of yourself. And for the rest of the population, hand washing and physical distance of 1.8 meters are the two strongest recommendations out there and the ones most effective. Of course, a well-used mask, with your hair up and not touching it from time to time, is a measure that helps. The same as the face shield,” explained the doctor.
In addition, doctor Guiselle Guzmán, head of the CCSS Collective Health area, points out the following measures to be taken:
“In Costa Rica, we are in stage or phase 3, however, according to the evolution of the disease, it is the responsibility of the Ministry of Health to determine and report the moment in which Costa Rica advances to phase 4 of community transmission. The priority measures of phases 3 and 4 are based on the strategy ‘Sampling (laboratory) / Identification of Cases and Isolation / Tracing of Contacts’ ”.
Costa Rica must be alert
Costa Rica had the lowest R – reproduction – rate in Latin America in mid-April, indicates an analysis by the Central American Population Center of the UCR (CCP-UCR) in an article on June 4.
The R rate explained:
- If R equals 1, the number of infected people does not increase or decrease over time, and the epidemic is under control.
- If R is less than 1, the epidemic is on the way to extinction.
- If the R is greater than 1, there is a proliferation and there may be an exponential increase in cases.
Costa Rica has “a worrying R of 1.88 with an upward trend,” the publication describes. This means that each patient infects almost 2 healthy people.