National Guard personnel were in charge of screening tests for Covid-19 at the Luis Muñoz Marín Airport. Associated Press photo/ Carlos Giusti.
Chronology of the crisis
The first reported case of Covid-19 originated in Wuhan, China, on December 31, 2019. The virus was previously unknown and spread rapidly within and beyond China. Many questioned its origin, supposedly from a mutation of a coronavirus that infected animals such as bats and pangolins. Another theory is that it originated in the Wuhan Virology Institute and the virus escaped by infecting workers at the institute. It is known that several fell sick just before the first case of Covid-19 was reported in Wuhan. Regardless of where and how it originated, once it was loose in the community, the virus spread rapidly throughout the world.
Despite what has been reported in the press, the first patient in Puerto Rico was not an Italian tourist who arrived on the Costa Luminosa cruise ship on March 8. The true history of the Covid pandemic in Puerto Rico began on March 3, 2020, when I saw a patient with classic symptoms of the illness: fever, cough, aches and diarrhea. I had been treating the patient for lymphoma since 2018 and had done a bone marrow transplant. At that time, we did not have Covid tests available in Puerto Rico and they had to be ordered through the Health Department, which in turn sent it to the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. It took me a week to convince the Health Department to order the test and finally administer it. The Health Department sent my patient’s test, along with that of the Italian tourist, to the CDC and the results for both arrived on March 13, when my patient had been waiting 10 days to confirm the diagnosis that I had made based on the symptoms. Governor Wanda Vázquez took the issue seriously and quickly took the right steps. That same day, all the public schools were closed and a curfew was ordered, telling people to stay at home except for emergencies or to buy essential items.
Advances in management of Covid-19
The first advance in managing the pandemic occurred when the important role of cortisone as an anti-inflammatory was discovered, whether using small doses of dexamethasone or, even better, relatively higher doses of methylprednisolone. We found that not all Covid patients needed treatment. In our experience, only 63% of cases needed cortisone treatment (“Home-based management…”, 2021). We have learned to identify those cases based largely on indicators of inflammation in the blood. Those who do not have inflammation can be managed at home and we have treated 132 patients this way. None have had complications nor have they had to be treated with cortisone. On the other hand, we have treated 76 patients with markers of elevated inflammation with methylprednisolone. Based on those markers, it was expected that 30 would develop insufficient respiration but only 4 developed that complication, which represents a highly significant difference from a statistical point of view (“Single-Arm, Open-Label Phase 2 Trial of Preemptive Methylprednisolone…”, 2021). The patients who were treated and had favorable results showed improvement in the markers of inflammation.
Of the 208 patients we have treated, whether without medication (132 cases) or with methylprednisolone (76), survival after 28 days was 98.6%. Being able to treat patients outside the hospital is a great advantage as they can stay at home with their families instead of having to be isolated in the hospital, detached from their loved ones.
One of the most notable complications developed by patients with this disease is what we call long Covid, which is defined as the persistence of at least one clinically relevant symptom after four weeks from the first day of the illness. These symptoms have varied and include extreme fatigue, respiratory difficulty, mental confusion, muscular or joint pain, and lost of the sense of taste or smell. In our study, we found that 30% of our patients developed long Covid, which was more common among patients who had elevated markers of inflammation.
Appropriate management of Covid-19 patients using cortisone is important in treating existing cases, but obviously it does not avoid the spread of the disease. Despite the curfew and the restrictions imposed by the government, Covid spread as expected, although at a slower pace than in other countries. By March 28, 2020, 21 new cases per day were reported and by June 24 that had quadrupled to 117 new cases.
The pandemic in Puerto Rico has had four waves. The first wave (Figure 1) was from July 6, 2020, to September 7, 2020, and was related to July 4 festivities, when many people gather and which resulted in more contagion. The incubation period for this illness is short, usually just 2-7 days, so it is not surprising that by July 6 the first wave began to appear.
From Johns Hopkins Coronavirus Resource Center, https://coronavirus.jhu.edu/data/new-cases-50-states/puerto-rico.
The first two waves were short in duration and intensity, probably due to the quarantine and other restrictions imposed by the governor. The second wave was from September 7, 2020, to October 9, 2020. The third and most prolonged of the waves was from October 10, 2020, to March 1, 2021. Its peak occurred on December 18, 2020, with 1,381 new cases that day. This third wave was more pronounced after the elections of November 3 because social distancing was not maintained in many voting sites. The fourth and final wave has been the highest, beginning in early April and reaching its peak on April 16, 2021, with 1,635 cases, the highest number of cases registered in one day since the beginning of the pandemic on the Island. This final wave began on March 1 and disappeared in the middle of June. It is not clear what led to this fourth wave. At the time this wave reached its peak on April 16, the population was already being rapidly vaccinated and 25% had received the vaccine. Since then, the curve has fallen rapidly. By the middle of June, 57% of the population had received at least one dose of the vaccine and 47% were completely vaccinated with two doses. At that time, 45% of the U.S. population was vaccinated.
Almost all the vaccinations in Puerto Rico have been with the Pfizer and Moderna vaccines, whose efficacy in clinical studies has been 95%, meaning that only one vaccinated person in 20 will catch the disease and this 5%, despite getting the disease, do not die. A small minority of our population has received the Johnson and Johnson vaccine, which is slightly less effective than the others available locally. Once the rate of new cases began to drop, hospitals began to have fewer patients in June of 2021. Despite the fact there is no adequate system of prevention on our Island, due to the privatization of medical services and the lack of a centralized infrastructure, the rate of hospital beds occupied by Covid patients dropped from an alarming 10% to half of 1% in June.
Mortality in Puerto Rico compared to other countries
Covid mortality in Puerto Rico, compared to other countries, is an interesting and pertinent discussion. In Puerto Rico, 1.89% of those infected with Covid have died, a figure similar to that of the United States, where 1.79% died, and better than the global figure of 2.17%. The mortality for people infected with Covid in Haiti is 2.16%, almost identical to the worldwide number. On the other hand, there is an even more important angle to mortality, because there is the rate of mortality among those infected and the rate of mortality from Covid in the entire population. The percentage of those infected who die may be low, but if a high number of inhabitants are infected, then the total mortality will be high. This aspect is measured in terms of the number of deaths per million residents. When we look at the number of deaths per million residents, we find some very enlightening data (see Chart 1). These statistics are from June 26, 2021.
|Country||Covid deaths per million residents||Covid infections per million residents||Population characteristics|
|Dominican Republic||352||29,807||70% blacks|
|Puerto Rico||797||43,846||25% blacks|
|Italy||2,112||70,575||8% “blacks and other ethnicities”|
Selection of countries with corresponding data by Dr. Fernando Cabanillas.
Figure 1 shows a correlation between the proportion of blacks in each country and the mortality from Covid 19 per million residents. Note that the black population has been affected with less severity. The information in the chart is organized based on the proportion of blacks in each country (fourth column), with those with the most blacks at the top. In the second column, we can see a gradual and very consistent increase in deaths due to Covid in countries with fewer blacks. Countries with less than 25% blacks have consistently had more than 1,000 deaths per million residents. Among the countries with the highest proportion of blacks, such as Tanzania, Nigeria and Haiti, the mortality per million is among the lowest in the world. In Haiti, 34 people per million have died, a very low number compared to its neighbor on the island, the Dominican Republic, with 352 deaths, more than 10 times as many.
The big exception is Cuba, which has fewer blacks, as reflected in the chart, than Puerto Rico and the Dominican Republic and would therefore be expected to have more deaths, but has many fewer deaths than expected. This is probably due to the fact that the public health program in Cuba has great control over Covid cases and therefore has kept rates of infection low, at 15,427 per million, the lowest among all the islands except Haiti. Logically, with the lowest rate of infection, fewer people will die.
African countries and Haiti have a high level of poverty and their mortality statistics should be among the worst, so these findings, not previously published, are counterintuitive. What is the correlation between the higher number of blacks and the lower mortality rate for Covid? We cannot say for sure, but it is reasonable to speculate based on the data available. We know that the Neanderthal genes are associated with greater susceptibility and mortality from Covid (“A genomic region associated…”, 2021). We also know that Neanderthals crossed with homo sapiens and they produced mixed homo sapiens that spread around the world. The mixed homo sapiens settled in Europe and Asia while the pure homo sapiens populated Africa, so it is logical to assert that where blacks predominate, especially pure blacks such as in Africa and Haiti, there is less mortality and fewer people infected by Covid-19.
The variants in Puerto Rico
At the beginning of the pandemic, the strain that came from China was called the wild strain. Later, the virus began to mutate. The first mutations resulted in a strain known as the British variant. The mutations associated with the variant made the virus more contagious and it soon replaced the wild strain in the United Kingdom and in the United States, as well as all of Europe and Puerto Rico. The British strain, also known as Alpha, is not necessarily more virulent, but it is more contagious. At the time of this writing there are 11 mutant strains, but the most important are the British (Alpha), the South Africa (Beta), Brazil (Gamma) and India (Delta) strains. All tend to be more contagious but the most concerning is the Delta variant, because it is 60% more transmissible, is characterized by a better union with the receptors of the lung cells and appears not to respond well to the monoclonal antibodies used to treat patients in the early stages of the illness. The Delta variant has displaced Alpha in Britain and the United States and therefore is expected to become dominant in Puerto Rico and the rest of the world. Two cases have been reported on our Island.
Not all vaccines protect against all variants, but rather have different levels of efficacy against different strains. For example, the efficacy of the Pfizer vaccine against the Delta variant is only 79%, compared to 95% against the Alpha variant and only 60% for the Astra-Zeneca vaccine compared to 73% against the Alpha variant. Fortunately, the Pfizer vaccine, although it is less effective, is 94% effective in protecting against hospitalizations for the Delta variant after just one dose and 96% effective after two doses. The numbers for the AstraZeneca vaccine were 71% after one dose and 92% after two doses. Therefore, it is very important that everyone receives both doses, especially those with lung disease, diabetes and heart problems, as well as others who are highly vulnerable and at greater risk of death.
Another effect: Post-traumatic stress syndrome
Pandemics not only directly affect the patients who are ill, but also have indirect effects on communities. One of these effects is post-traumatic stress syndrome, and is very evident in the Covid-19 pandemic. It has not received much attention in the press, however, and often has not been attributed to the pandemic. Once the epidemic began to subside in the United States, young people began to go out and travel, taking advantage of significant discounts on airline tickets and hotels. This has directly affected our population. Cases of violence by tourists is something new we have seen. One example occurred in the Rare restaurant in Miramar. After eating all they had been served, five tourists complained that they had not liked the food and refused to pay. When the restaurant threatened to call the police, they turned violent and tried to attack the waiter and later went outside and began throwing rocks at the restaurant. The police had to intervene and block Madrid Street in both directions. The tourists ended up in jail, except for one, who could post bail. The others were held in prison for two weeks. Some think this and other incidents are not linked to the pandemic, but several experts have concluded that cases of violence by tourists on airplanes are associated with post-traumatic stress syndrome caused by the pandemic. Several cases have been reported on both national and international flights in which tourists inside the planes have become violent among themselves or with the crew. This has been seen in the form of refusal to wear a required face covering during the flights.
Impact on the economy
The bubonic plague pandemic in the 14th century seriously affected the economy of Europe. Reducing the population by half, it caused a serious shortage of farmers, causing an increase in the cost of labor. All of this contributed to the acceleration of the fall of the economic system of feudalism and led to the transition to capitalism.
The effects of Covid on the economy have also been felt in Puerto Rico, although not with the severity of the bubonic plague. Many businesses have closed, especially restaurants. Both the travel and entertainment industries have been seriously affected simply because people have stayed home and rarely go out to eat or travel.
Hardware stores in Puerto Rico have been seriously affected, unable to maintain inventory, which has caused a notable increase in the prices of many items, which have doubled or tripled, and our ability to find them (“Complicado el panorama…”, 2021). Scarce items include steel rods, lumber, pipes, PVC, and other items, particularly those from China, Spain and Chile. This is because many factories closed during the pandemic. The cost of transportation of materials from China to Puerto Rico has increased to four or five times as much as normal. This latter phenomenon is an interesting one caused by a shortage of containers for transporting materials. In the first half of 2020, the pandemic caused many countries to confine their populations, causing a significant deceleration of global trade, with the result that thousands of containers remained in Europe and the United States (“Shipping costs quadruple…”, 2021). Later, in the second half of the year, the pandemic situation improved and the economy rebounded, causing greater demand for products from Asia, not only creating strong competition for containers but also a high volume of cargo in the ports, which could not handle all the traffic. The congestion in the ports caused some shipping companies to raise their prices to compensate for the longer time it took to process containers. This, along with increased demand, has caused a marked increase in prices as well as delays in the time it takes for articles to arrive to Puerto Rico.
How and when will the pandemic end?
It is impossible to predict the future of the pandemic with certainty, but taking into account the lessons of the past, quarantines, personal hygiene and herd immunity were considered the keys for putting an end to the bubonic plague. Identifying the method of transmission and recognizing that fleas were a vector, contributed to controlling the plague. By identifying the bacteria Yersinia pestis, an effective antibiotic treatment could be applied, which also helped eradicate some sporadic outbreaks that were potential centers of contagion.
Other epidemics, such as smallpox, which had a 30% mortality rate, have been controlled thanks to vaccinations that produced the desired herd immunity. Since 1979, not a single case of smallpox has been registered in the entire world.
In summary, quarantines, hygiene and vaccines are the keys for ending pandemics. If there were an effective antiviral treatment, which we currently do not have for Covid-19, that would also help. U.S. President Joe Biden has decided to invest $3.2 billion to develop oral treatments for viruses in general.
The end of a pandemic does not mean that cases never appear again. That has only occurred with smallpox and polio in countries where vaccination has been successful. To achieve this, it is necessary to reach herd immunity, which means that the great majority of the world population has been vaccinated. The level for herd immunity is different for each virus. To eradicate polio and smallpox, 80% of the global population had to be vaccinated, but we do not know what level is necessary for Covid-19. If we do not reach herd immunity, we will continue having sporadic cases, which is what will probably occur in Puerto Rico, unless we can convince the segment of the population that refused to be vaccinated. Also, we are far from having all the countries of the world reach herd immunity, which means that after we reach this desired percentage, some other case will be imported from other countries that do not have a high vaccination rate.
The type of vaccine is also important, as we know that some, such as those from China (CanSino, CoronaVac, Vero and Sinovac) have efficacy that ranges from 50-78%. These are used a lot in Latin America. The herd immunity obtained with more effective vaccines such as Pfizer and Moderna will probably be more effective than the Chinese vaccines. This factor complicates the outlook for reaching global herd immunity.
One obstacle to ending the pandemic are the variants. The only way to control the rise of more variants is through vaccination. Without massive vaccinations, the virus will continue to proliferate and the more it spreads, the more resistant mutations will arise. Therefore, vaccination is not just an issue of protecting ourselves, but also a question of social conscience and responsibility. If we achieve the goal of 80% vaccinated, Covid-19 will probably become just an occasionally annoyance for those vaccinated and will no longer be a serious world threat.
Cabanillas, Fernando, Javier Morales, José G. Conde, Jorge Bertrán-Pasarell, Ricardo Fernández, Yaimara Hernández-Silva, e Idalia Liboy. “Home-based management of COVID-19 by identification of low-risk features”. medRxiv. 2021. https://pubmed.ncbi.nlm.nih.gov/33532797/.
Cabanillas, Fernando, Javier Morales, Jorge G Conde, Jorge Bertrán-Pasarell, Ricardo Fernández, Yaimara Hernández-Silva, et al. “Single-Arm, Open-Label Phase 2 Trial of Preemptive Methylprednisolone to Avert Progression to Respiratory Failure in High-Risk Patients with COVID-19”. medRxiv. 2021. https://www.medrxiv.org/content/10.1101/2021.03.08.21253117v1
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Author: Fernando Cabanillas, MD
June 27, 2021
Edit: Dr. Lizette Cabrera Salcedo