In recent days, the highest levels of the Government and public health experts have known this, but nobody wants to say it openly: thousands would die from COVID-19 in Puerto Rico.
At the moment the projections obtained from experts by the Center for Investigative Journalism (CPI) are overwhelming. The most cautious suggests that some 16,000 fatalities could be registered during the pandemic on the island; the worst case scenario approaches 58,000 victims.
At the request of the CPI, the health demographer Raúl Figueroa calculated the number of possible deaths, using as a basis the contagion estimates that the Government of Puerto Rico has offered, as well as the fatality rates published by the leading countries in the pandemic, and the local case-fatality rate that the few tests that have been done on the island since the first test was carried out on March 8. According to Figueroa’s calculations, in the event that Puerto Rico approaches the world average lethality – which to date is 4.4% – 27,000 people would die in about 12 to 18 months. If the epidemic behaved here as in Italy, which has an aging population similar to that of Puerto Rico and the worst rate to date with 9.3%, it would be 58,000 deaths in the same period.
In the next three to six months, the most likely scenario would be 1,400 to 12,000 victims, Figueroa estimated, predicting that Puerto Rico will see an explosion of cases in the next two weeks.
“The people who are going to die are many, especially if this social isolation does not work,” he said.
The demographer’s estimates were validated by two epidemiologists consulted by the CPI and, to a large extent, by the biostatistician of the COVID-19 Task force and director of the School of Epidemiology and Biostatistics of the University Medical Sciences Campus (RCM) of Puerto Rico, Dr. Juan Carlos Reyes.
To questions on the subject, Dr. Reyes said in an interview with the CPI that the most conservative scenario projected by the Task force would be about 16,000 deaths and the worst scenario – which he acknowledges is a worldwide average – 20,700 deaths in the same time frame.
“We are not far from those numbers,” he acknowledged when he saw the projections made by Figueroa. He emphasized that the projections of the Task Force’s epidemiology committee are based solely on the experience of contagion and lethality that they have registered in Puerto Rico with the few tests that have been carried out so far.
The other two epidemiologists consulted by the CPI – Dr. Cruz María Nazario, from RCM and Dr. Melissa Marzán, from Ponce Health Sciences University (PHSU) – validated the projections making the same qualifications as Reyes.
Nazario, for example, emphasized that the figures are crude estimates, that do not take into account fluctuations by age and sex, but indicated that it is the type of projection that can be made given the lack of tests done in Puerto Rico and specific data. about the positive cases.
“The estimate of deaths is correct,” he said.
For her part, Dr. Marzán validated the range of possible deaths projected for the next three to six months as the direct deaths that can be expected in Puerto Rico at the peak of the epidemic, if social distancing measures manage to reduce the advance of the contagion.
The experts consulted emphasized that the projections and scenarios will depend on the containment measures that the Government takes and on the resources that it can bring to the country’s deteriorated health system. However, they agreed to anticipate that what one can aspire to is to lower the number of deaths from COVID-19, not to prevent a significant number from occurring given the demographic reality of Puerto Rico and the health system.
Epidemiologist Dr. Idania Rodríguez, who has worked in the Department of Health and in the Institute of Statistics of Puerto Rico, also pointed out that the island has a large number of inhabitants over the age of 60 and people with chronic conditions in all segments. demographics such as diabetes, cancer, hypertension, respiratory diseases and heart disease, which have been in the highest lethality segment in China, Italy and Spain. In Italy, for example, the coronavirus case fatality rate among older adults is 19%.
The three epidemiologists said in separate interviews that the island’s health system will not be able to handle the enormous number of hospitalizations that would occur, causing many of the deaths of severe patients in vulnerable segments. Marzán maintained that these would be indirect deaths from the epidemic.
Estimates of how many people are expected to be hospitalized for COVID-19 simultaneously at the peak of the epidemic fluctuate between 30,000 and 50,000 people; Puerto Rico only has 8,000 hospital beds between public and private facilities, so the Government is already looking for alternatives to convert other properties where to place temporary hospital beds for patients, the CPI learned.
“Could we hospitalize 50,000 people at once? The answer is no and that would impact the estimate of indirect deaths, ”said Marzán, indicating that as a lesson from Hurricane Maria, the Government should have established those definitions before the critical event, so that the severity of the epidemic can be properly documented. “I fear that, like the hurricane, deaths will have to be estimated through excess mortality during the epidemic period,” he added.
For her part, Dr. Nazario also emphasized the lack of preparation on the part of the Department of Health (DS) that did not take the forecasts since it became known about the start of the spread of the virus in January.
“We did not prepare, just as we did not prepare for Hurricane Maria. We should have been preparing since January. We are behind and, as in Maria, the people who are going to die from COVID-19 are basically because we do not have enough intensive care beds, nor do we prepare ourselves, ”he said. He explained that in an extraordinary public health event like the current pandemic there are deaths that are inevitable, but there are deaths that can be avoided if it has been planned and resources have been aligned in time.
For her part, Dr. Marzán maintained that the quarantine that has been maintained to date on the island remains one of medium intensity, since it still allows the circulation of a large part of the population, even if it is for basic matters such as food and gasoline. . He estimated that currently one in four people is still mobile, while in the strictest possible scenario only first responders could circulate in an emergency, or approximately one in eight inhabitants.
“I am very concerned because I feel that people are doing this (quarantine) very lightly. Very few people are taking this seriously, ”added Dr. Reyes of the Task force.
As of Wednesday morning, 582 tests had been done between the Health Department, the Veterans Hospital and the private laboratories that began testing this week. Currently there are 51 positive results and 178 pending results. Globally, it is estimated that for each positive case, there are between five to 10 positive people who have not been detected and a transmission rate (people who infect other people) of 2.3. For this reason, the Task force estimates that, as of Wednesday, March 25, in Puerto Rico there are between 586 and 1,173 infected, Reyes explained.
Reyes argued that the problem with the inaccessibility of the tests in Puerto Rico comes down to the fact that there are simply no molecular tests available on the island (PCR), as in the United States, since the rapid tests that were requested have not yet arrived. . According to what he said, the Health Department had 1,000 tests, of which as of Wednesday there should have been 642 after the 358 that the agency has done because they have not received new ones. This is why they have been concentrating on severe cases, he explained.
He also explained that the limitation in the tracking of people who have been in contact with those who have tested positive responds to the lack of resources in the Health Department and indicated that they are recruiting epidemiology students from the RCM and the PHSU to start to provide support in this task starting Thursday or Friday this week, and once the rapid tests arrive, they will try to test those people, which is ideal, Reyes acknowledged. His expectation is that this will happen in the middle of next week.
Likewise, he affirmed that the position of the Task force is that once said 200,000 tests arrive, they are spread throughout the island and they are also made to people with mild or asymptomatic symptoms, which are the main sources of contagion of the virus because they feel the Well enough to keep going to the grocery store, bank, grocery store, and pharmacy, and they continue to spread the virus. As indicated, the scientific literature on the subject, which is already solid, suggests that 79% of people who have the virus are being infected by people who have mild symptoms, and that 86% of people are infected and unknown.
In other words, the biggest problem of contagion is in people who do not get sick even though they have the virus, so-called asymptomatic people who continue to circulate and spread, not in those who get seriously ill, and who are contained in a hospital, he said. Therein lies the importance of so-called contact tracing, to slow down the rate of spread.
“Of those who are being treated right now we are not tracking anyone,” said Dr. Idania Rodríguez, emphasizing the importance of identifying those people who have had contact with cases that have already tested positive and putting them in total isolation. The epidemiologist also regretted the lack of evidence and data in Puerto Rico because it prevents early identification of where the contagion pockets are.
“The consequence is that you don’t know the extent of the disease, and you don’t identify those who are at risk. You cannot have the mitigation and containment measures, and these people can continue to transmit the disease, “he said.
He also maintained that many of the measures that the population is taking, such as using masks and gloves, what they do is give a false sense of security and tend to further spread. For example, if a cashier or a consumer uses gloves, and with the same gloves, they grab all the products they buy and the money they pay with, which in turn have already been touched by many other people, the glove does not have any effect. In addition, contaminated products then enter your home and touch them again, so they can also be sources of infection if you do not clean them one by one with a vinegar solution or diluted soap.
“There are factors that are not in you, because if someone touched something in the supermarket, the infection will continue. It lasts two or three months, it would be delusional to think that this will end in two weeks.
There is no way to guarantee non-contagion, the only thing we can do is do everything possible to minimize it, “he concluded.
