Coronavirus landed in Latin America in February 26. We had the opportunity to see the consequences of the disease in other parts of the world and had some weeks to prepare our health systems to face the pandemic. Unfortunately, most countries in Latin America share having health care systems with great deficiencies and governments that minimized the Coronavirus problem. Also, many people in this region live in poverty and need to keep daily activities in order to eat and provide their family with basic needs. Another common problem in the region is the lack of testing or testing that take more than 2 days to bring back results. Since the beginning it was very difficult to detect and isolate positive cases and avoid the rapid spread of the disease.
The region is now facing the exponential growth in Covid-19 cases, health-care systems are reaching their highest capacity, many people are not following the quarantine and mortality is higher than in other parts of the world.
The peak of the pandemic is still waited for the second part of May or June in many of these countries. This means, we will be seeing a devastating scenario in the following weeks.
OVERVIEW IN LATIN AMERICA:
Mexico: 20,739 confirmed cases, 1972 deaths, Recovered 212,377.
First case reported in Feb 29.
Main affected states: Mexico City (5,548, 346 deaths), State of Mexico (3,422 cases, 257 deaths) and Baja California (1569 cases, 231 deaths).
Many cases in Mexico City are related to a big market “Central de Abastos” where activities continued normally with large numbers of visitors until last week.
Big Institutions in Mexico City are full. Sedation of patients with poor prognostic to make ventilators available for patients who have better opportunities to survive.
High mortality compared to other countries: 9.5%. This could mean underreport of total cases or higher mortality because of risk factors in our population: Obesity, Diabetes, hypertension, difficult access to healthcare…
Unfortunately, we still see part of our population out of their homes and in crowded activities.
High percentage of health workers infected. Not enough help from government to get PPE. They have to buy it themselves or get it from donations from private initiatives.
Lack of health care workers in many hospitals: because they get sick from Coronavirus, because they work in more than 1 hospital and are covering longer shifts now.
Ships 8-12 hours. During this time health personnel do not drink water or take out the PPE.
Recycling of N95 masks to prolong their use.
Brazil: 91,589 cases. 6,329 deaths. Both increasing.
Mortality rate: 6.9%
Testing numbers remain lackluster and the actual number of infections is significantly higher.
Sao Paulo, the most populated region, is by far the worst affected region in Brazil. Public healthcare systems are on the verge of collapse.
First case in Latin America and Brazil: February 26.
Peak expected by the end of may.
This is the epicenter of the pandemic in Latin America
Colombia: 6,507 cases, 293 deaths.
Mortality rate: 4.5%
>40% of cases in Bogotá
First case in the country: March 6.
Peak expected by the end of may.
Perú: 40,459 cases. 1,124 deaths.
Mortality rate: 2.77%.
Second in cases in Latin America, after Brazil.
First case reported in March 6.
Most cases in Lima.
In quarantine since March 16.
Peak expected the second week of may.
Movement of people trying to return to their hometowns and get out of urban areas.
Total population 32 million, they had a total of 500 intensive care unit beds at the beginning of their pandemic.
Currently they have 3968 patients in hospitals, 568 in intensive care on mechanical ventilation.
Panamá: 6,720 cases. 192 deaths.
First case: March 9.
Active cases: 4.1% hospitalized and 1.5% in ICU.
Peak: first half of may.
Argentina: 4,415 cases, 218 deaths.
Mortality rate: 4.9%.
First case: March 9. They had 9,000 ventilators available.
Strict quarantine since March 20.
15% of cases among health-care workers.
Peak expected by the end of may.
Costa Rica: 725 cases, 6 deaths.
Lowest case fatality rate in the Americas: 0.86%.
First case: March 6.
People on strict quarantine.
Strong health-care system.
Regulatory timelines in Latin America
Most countries have established fast track review for Covid-19 related clinical trials.
|Costa Rica||1 week|
Updates Covid-19 treatments:
- In a cohort study of 90 hospitalized patients with Coronavirus disease, use of Hydroxychloroquine with or without Azithromycin for treatment of Covid-19 was associated with frequent QTc prolongation. Greater risk in those taking hydroxychloroquine and azithromycin. (JAMA, May 1)
- Convalescent plasma: promising, not yet shown to be effective. Clinical trials are being conducted. By April 27, 2115 sites had registered to participate and enrolled 5968 patients, 2576 of whom had received convalescent plasma.
- Tocilizumab: human monoclonal antibody against IL-6 receptor. IL-6 increase in patients with Covid-19 and Cytokine storm release syndrome. Early data from a study in France, showed benefit from Tocilizumab significantly decreasing the number of deaths or life support interventions compared to a control group. Additional research is required to validate the drug´s effectiveness and potential side effects. On March 19, Roche confirmed initiation of a Phase III trial in collaboration with BARDA in patients with Covid-19 severe pneumonia.
- Remdesivir: clinical trial in China that included 237 adults with Covid-19 pneumonia, randomized to receive Remdesivir vs placebo + standard of care showed no significant difference between groups in time to clinical improvement, mortality or time to clearance of virus in patients with serious Covid-19 compared with placebo. But, Remdesivir group had a numerically faster time to clinical improvement that those receiving placebo, they didn´t meet their recruitment target and considerations on patients starting the antiviral earlier in the disease could mean a difference. (LANCET, APRIL 29). Early results from other clinical trials show more promising results with improvement in recovery time. This means this drug has certain antiviral effect on Coronavirus and might be effective, especially in the first 10 days of the disease, but is not a definite treatment for it.
Updates Covid-19 vaccine:
>90 candidates in development
8 in clinical trials
Around 12 months to have a vaccine proven to be safe and effective
Global distribution of the vaccine will be the challenge
Coronavirus in special populations: Children
What we know: 72,314 cases in China showed that less than 1% of cases were in children younger than 10 years of age. A review of 1391 children in China assessed and tested showed that 12.3% (171) were confirmed to have SARS-CoV-2 infection. Median age of infected children was 6.7 years. Fever was present in 41.5% of the children at any time during the illness. Other common symptoms included cough and pharyngeal erythema. 27 patients (15.8%) did not have any symptoms of infection or radiologic features, and 12 patients had radiologic evidence of pneumonia but no symptoms of infection. During the course of hospitalization, 3 patients required intensive care support and invasive mechanical ventilation, all had coexisting conditions. Only one fatality occurred in a child with intussusception and multiorgan failure.
Another report from Italy showed that children younger than 18 years of age who had covid-19 composed only 1% of the total number of patients in the country. 11% of these children were hospitalized and none died.
Another cohort study described 100 italian children younger than 18 years of age with Covid-19 diagnosis, assessed in pediatric emergency departments. The median age of the children was 3.3 years, exposure to an unknown source of the infection or from outside the family accounted for 55% of the cases. A total of 12% children appear ill, and 54% had a temperature of >37.5. Common symptoms were cough (44%) and difficult feeding (23%). 4% had low oxygen saturation levels and evidence of lung involvement. 9 patients required respiratory support, 6 of these with comorbidities. 21% were asymptomatic, 58% had mild disease, 19% had moderate disease, 1% had severe disease and 1% had critical disease. Severe and critical cases were diagnosed in patients with coexisting conditions. No deaths were reported.
Another report of 36 children in China had similar features and no fatalities.
According to these publications most infected children appear to have a milder clinical course than adults. Asymptomatic infections are not uncommon among children. Most children that present with severe or critical disease have underlying conditions that predispose them. Fatality rate is lower than in adults.
These favorable outcomes have many theories: children are often exposed to other Coronavirus during winter months in Schools and may have some cross antibodies for defense, they have less receptors to the virus and their “immature” immunological system do not react as violently as the one in adults when they acquire the infection.
Still, they can be asymptomatic carriers and take the virus home to family members with risk factors, so understanding the behavior of the disease in them and developing a vaccine that could protect children from SARS-CoV-2 seems to be an important step to control the pandemic.