Priorities for dealing with Nicaragua’s new COVID-19 phase

Nicaragua’s Academy of Sciences organized an international seminar in August to analyze the country’s real COVID-19 situation. Twenty-one scientists, 10 of them Nicaraguans and 11 from Argentina, Brazil, Canada, Colombia, Costa Rica, Honduras and the United States, exchanged information and their own experiences and hammered out a policy proposal for the pandemic, with specific recommendations for getting ag rip on it. This is the text that came out of that seminar, with a few figures updated for October.

Academy of Sciences of Nicaragua

Nicaraguans have been hit hard by COVID-19. The pandemic has caused many deaths, as well as significant economic losses due to the downturn in productivity and business closures. The COVID-19 Citizens’ Observatory estimates that as of October 21, 2020, there have been at least 10,778 suspected cases and 2,780 deaths, which translates to 435 deaths per million inhabitants: one of the highest mortality rates in Latin America. In contrast, the official count as of the same date only recognizes 155 deaths and confirms just 5,434 cases. For economic context, in a June 2020 poll, 31% of the Nicaraguan businesses surveyed reported being moderately affected by the pandemic, 47% reported serious financial losses and 33% indica-ted they had fired workers.

The government
must change course

Nicaragua is experiencing a dramatic health crisis that began over six months ago, when on March 18 authorities repor¬ted the first death from COVID-19. The Nicaraguan government failed to take appropriate measures to control the epidemic, leading to runaway transmission that threatens regional security.

The Ortega government required neither self-quarantining nor social distancing, even though they are two of the most effective epidemiological tools to deal with any infectious disease outbreak. Furthermore, authorities insisted on keeping public schools and universities open, and on attendance by government employees and supporters at public gatherings, festivals and sports events.

When the pandemic hit, Nicaragua was already the second poorest country in the hemisphere and its economy was in free fall as a result of the prolonged political and social upheaval that began in April 2018. Its fragile public health infrastructure was hardly prepared to provide timely, competent services; its conditions were no match for this pandemic’s destructive force.

Several medical associations, the Multidisciplinary Scientific Committee, civil society organizations and Nicara¬gua’s Academy of Sciences (ACN) have actively urged the government to design an effective national strategy to deal with the pandemic and apply measures to prevent or mitigate the spread of the disease. Unfortunately, this has not happened. The government must map out a different route to appropriately and effectively fight the COVID-19 outbreak.

T

he meeting’s purpose

In light of the government’s inaction, the Academy of Sciences of Nicaragua, in collaboration with the Inter-American Network of Academies of Sciences (IANAS), organized an international seminar on COVID-19 in Nicaragua, with two objectives: to compare how Nicaragua and other countries addressed the epidemic, and to develop a policy report for providing an appropriate response to the health crisis.

During the on-line seminar, held on August 20 and 21, 2020, experts from different IANA academies discussed the COVID-19 crisis and its impact on health and societies around the world. They contemplated best practices and strategies in diverse geographic areas and shared insights into the implications for medical and scientific organizations in the region. They also set up a working group to prepare a report on COVID-19 policies in Nicaragua. The experts recognized the difficulties inherent to Nicaragua’s situation and focused their attention on actions and recommendations to ensure an immediate and appropriate response to the crisis. This document is the result.

The price paid is enormous

The crisis provoked by COVID-19 is one of the most difficult challenges humanity as a whole has faced. In Nicaragua, the lack of an adequate plan to deal with the pandemic has exacted an enormous price from individuals, communities and society at large. If this situation is not rectified with appropriate policies, the crisis could lead to greater poverty, inequality and exclusion, as well as further destabilization throughout the country.

This policy report, prepared by scientists and experts from several Academies of Sciences around the continent, reviews the pandemic’s current situation both globally and in Nicaragua, with the goal of helping to map out a new national focus for confronting the spread of coronavirus in the country. The document analyzes best practices and strategies in several countries and examines the role of civil society and medical and scientific organizations in providing evidence-based data for better-informed decision-making.

The report contains several proposals: Strengthen Nicaragua’s response to COVID-19 with an in-depth mitigation plan and a citizens’ plan including sector-based activities for preventing contagion and transmission of SARS-CoV-2; respond, including vulnerable individuals and communities; and monitor epidemiologically with broad-based, decentralized application of diagnostic tests in large urban populations and effective contact tracing. The report also presents specific policy recommendations for health workers.

Bearing in mind that Nicaragua alone cannot respond adequately to the health crisis, involving multilateral financial institutions and international organizations to coordinate these responses is recommended.

An easily transmitted virus

Coronavirus is a large family of viruses that can cause illness in animals, including humans. The most recent discovery is Severe Acute RespiratorySyndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19, a zoonotic disease that can be transmitted between animals and human beings and today has spread rapidly around the world. While the original source of SARS-CoV-2 is unknown, some studies have indicated that horseshoe bats and pangolins are involved.

The majority of SARS-CoV-2 infections are mild and up to 40% are asymptomatic. However, infection can also cause a serious illness that leads to a high rate of hospitalization and death. The COVID-19 death rate can be as low at 1% or as high as 6% or more. A recent review indicates that the COVID-19 lethality rate varies markedly by age: from 0.03% in patients under 18 years old to 30% in patients 85 years and older.

The virus is easily transmitted from person to person via respiratory droplets and, probably, by aerosols: even smaller particles that stay in the air after talking, singing, coughing, etc. It is also transmitted by touching objects and surfaces that have been contaminated by an infected person. Infected individuals are contagious one or two days before showing any symptoms. For this reason, it is essential for society to adopt preventive measures: use of masks and alcohol-based sanitizers, regular handwashing with water and soap, 2-meter or greater social distancing and self-quarantine wherever possible.

After-effects more serious than the disease

The most common COVID-19 symptoms are fever, dry cough and fatigue. Around 45% of patients show respiratory and digestive symptoms. Other symptoms include anorexia, diarrhea, stomach pain, loss of taste and loss of smell.

As the pandemic spread throughout the American continent, it became clear that after recovering from COVID-19, there may be clinical sequelae that are even more serious or dangerous: thrombotic events that can lead to strokes, myocardial infarction, pulmonary embolism and sudden death. Serious neurological complications are also common, and many survivors show lasting cognitive deficits (brain fog) or depression.

The main risk factors are advanced age, pulmonary and cardiovascular diseases, hypertension, diabetes and obesity.

Among the Hispanic population in the United States, 35% of deaths occur in people under 65 years old. Compared to women, men infected with COVID-19 are at higher risk of death and of suffering more serious symptoms and after-effects, regardless of their age. Men also face higher levels of stress, anxiety, depression and other mental illnesses.

Which treatments have been best?

Although there is no standardized treatment for COVID-19, positive preliminary results have been shown with remdesivir, dexamethasone and anti-coagulants. Using these medications leads to better outcomes, including patient survival.

Data on the effectiveness of convalescent plasma and/or hyperimmune globulin are still preliminary. Some studies do show possible benefits, but in a randomized trial conducted in China with COVID-19 patients, convalescent plasma did not shorten recovery time. Trials are underway testing anti-viral therapies, immunomodulators and anti-coagulants. Some medications (hydroxychloroquine, azithromycin, Kaletra, acyclovir, ivermectin and interferon) have no beneficial effect and are not recommended, despite some politicians frequently promoting them.

A rapidly spreading virus

After the novel coronavirus was identified in late December 2019 as the cause of pneumonia cases in Wuhan, it rapidly spread throughout China and immediately there was a growing number of cases all over the world.

In the United States, the first case was reported on January 21, 2020. The first three cases detected in Europe were reported in France on January 24. On February 26, Brazil’s Health Ministry reported the first case there. On March 6, Costa Rica reported its first cases. And on March 18, Nicaragua’s Ministry of Health confirmed the first case in our country.

SARS-CoV-2 spread rapidly around the globe and on March 11, 2020, the World Health Organization (WHO) classified it as a pandemic. As of September 2020, 85% of countries in the world had reported cases. However, patterns of infection have differed from one country to another. In Asia and Europe growth was very quick, whereas in America the virus spread more slowly, but the peak of the curve has lasted longer.

As of September 19, 2020, around 30 million COVID-19 cases and around 1 million deaths were confirmed worldwide. The American continent has been the most affected, with over 12 million confirmed cases and a very high mortality rate. All over the world official statistics undoubtedly underestimate the pandemic’s magnitude with respect to both case counts and number of deaths, since the quality of data collection varies significantly from country to country.

A disease of the poor

In most countries COVID-19 is becoming a disease of the poor and neglected. The most vulnerable sectors of society are experiencing a greater number of infections and deaths; migrant populations and indigenous, brown and black communities are the most affected.

A combination of factors—greater exposure to the virus, diseases associated with poverty and more limited access to medical care—leave the poor exceptionally vulnerable to COVID-19. Despite this, the most affected countries have been those of the G-20. This suggests that the problem is not simply a lack of resources. It is also the lack of intelligent decision-making and management, combined with lack of testing and of policies requiring isolation. The problem lies in both promoting measures and raising awareness.

Political management of the pandemic

Some countries—Taiwan, Vietnam, South Korea, Germany and New Zealand—have handled the pandemic more efficiently, with rapidly-implemented action plans and well-defined goals with specific timeframes. These actions included contact tracing, large-scale testing, political leadership and community participation.

Another important factor has been the level of participation among the scientific community, with research, exchanges and provision of data to governments and political leaders, which facilitated evidence-based decision-making. For example, the Royal Society of Canada has set up a working group of clinical and academic experts who provide evidence-based data to conribute to the making of more informed decisions for recovery in that country.

Other countries have managed the pandemic poorly: the United States, Brazil and Mexico are noteworthy examples. The United States experienced delays in testing and the government was unable to develop and implement a national strategy, leaving the states to fend for themselves and, in some cases, compete among themselves to obtain desperately-needed supplies from the Federal government.

Leaders of those countries that have managed the pandemic poorly have also minimized the seriousness of the illness as well as the need to use masks and practice social distancing. At the same time, under pressure to return to normalcy, they have reopened their economies prematurely, with disastrous results. According to an analysis by Johns Hopkins University, Peru has the highest per-capita mortality rate in the world (100.48 deaths per 100,000 inhabitants) even though it imposed a national quarantine at the start of the pandemic.

The consequences of
“medical populism”

The progression of COVID-19 has been accompanied by a lack of adequate information and even by disinformation. Fake news has played an important role in blocking an effective response to the pandemic. Harmful substances have been promoted as miracle cures or prophylactics; health workers have been demonized and attacked and their diagnostic materials have been destroyed. And in several countries, such as the United States, a faction even believes the pandemic is a hoax.

A Lancet COVID-19 Commission summed up the damage stemming from this “medical populism”: “Another reason for the failure to control the pandemic is a style of political leadership that has been called medical populism.” Medical doctor and anthropologist Gideon Lasco has described it as the product of leaders “simplifying the pandemic by downplaying its impacts or touting easy solutions or treatments, spectacularizing their responses to crisis, forging divisions between the ‘people’ and dangerous ‘others,’ and making medical knowledge claims to support the above.”

Lasco uses three case studies to present his argument: the President of the United States, Donald Trump; the President of the Philippines, Rodrigo Duterte; and the President of Brazil, Jair Bolsonaro. Medical populism not only hampers the implementation of non-pharmaceutical interventions, it also stokes opposition to simple measures, such as using facemasks, and generates both misinformation and rumor-mongering.

Nicaragua’s erratic
handling of the pandemic

On March 12, 2020, representatives from eight countries of the Central American Integration System (SICA) joined forces to analyze the pandemic situation in the region and developed a joint action plan to deal with the spread of the virus. Nicaragua was the only country to ignore this plan, which required quarantine, suspension of classes, restrictions on public events and other measures.

The COVID-19 crisis hit Nicaragua in the midst of a recession and a serious socioeconomic and human rights crisis that began in April 2018. Nicaragua is currently experiencing extreme polarization from the socio-political conflict, and crime, violence and economic fragility have all increased in a country where 70% of the people only find work in the informal sector, where they lack both labor rights and social security.

The erratic way the Nicaraguan government has approached the pandemic has worsened this situation. Since March, it has said there would be no quarantine in Nicaragua, and to date, entertainment centers, businesses, schools and universities have all remained open. Furthermore, authorities minimized the true extent of the pandemic, repeatedly refusing to establish mandatory health measures, and harassing and punishing health workers who use personal protective equipment. The government has ignored WHO recommendations, including even the most basic measures, such as social distancing. Instead, it has continued sponsoring and promoting meetings, festivals and massive sports events.

National response
to the pandemic

Nicaraguan civil society has played an important role in addressing the pandemic. Since January 2020, the Multi¬disciplinary Scientific Committee has worked with medical and public health professionals to promote a range of initiatives and provide scientific guidance on the pandemic to society at large.

Nicaragua’s Academy of Sciences has also been visibly active in promoting prevention and hygiene measures: it published an interdisciplinary book of essays on the pandemic in Nicaragua, written by collaborators from a variety of scientific disciplines and including technical data on the virus and its social, economic and environmental impact.

In general, Nicaraguan society has responded positively to the recommendations we have made. Many have decided to protect themselves using masks and hand sanitizer, and practicing social distancing and self-quarantining. We believe this has helped strengthen a national response to the pandemic.

COVID-19 Citizens’ Observatory

There is little trust in Nicaraguan government data on COVID-19 in the country. Since the first positive case was presented, there have been serious problems with the accuracy and transparency of official information. This is why international health organizations have had to depend on independent sources in the case of Nicaragua, such as the nongovernmental research group, COVID-19 Citizens’ Observatory.

Health workers have faced exceptionally traumatic conditions during the pandemic. In the worst months (May and June), they were working completely unprotected and experienced high levels of physical and mental exhaustion, especially in the public sector. Data from the COVID-19 Citizens’ Observatory estimate that as of October 21, 814 health workers (including 487 doctors) had been infected and 108 had died; 40 of the latter doctors.

In the international on-line seminar organized by Nicaragua’s Academy of Sciences in August with support from the Inter-American Network of Academies of Sciences, to contribute to dialogue and analysis regarding the pandemic in Nicaragua, national and international experts participated in discussions of their personal experiences in the fields of epidemiology, molecular biology, immunology, medicine and vaccine development.

In addition to promoting such debates in the future, the goal of the seminar was to prepare a policy report on COVID-19 in Nicaragua, proposing evidence-based policies and recommendations. Regardless of whether or not the Nicaraguan government takes the policies and recommendations proposed here into consideration, they will be valuable for the public in general and for future pandemics.

A mitigation plan with
experts and citizens

Absent effective treatment or a vaccine, limiting the spread of the virus is the best protection against COVID-19. Given that containment of the outbreak in Nicaragua is currently impossible, a national mitigation plan must be drawn up with help from experts. This plan should address monitoring, detection, response and control of outbreaks; promoting hygiene to prevent infection; localized quarantine and social distancing measures, plus the use of masks to reduce transmission of the virus.

If guidance from authorities is missing, civil society could implement a citizens’ plan, including self-protection measures to limit SARS-CoV-2 transmission, which would reduce the probability of another outbreak. The plan would ensure clarity of roles and coordination mechanisms within the health system, with public participation in a community-based approach to stem the impact of COVID-19.

Following WHO recommendations, stopping transmission and protecting communities will require the participation of all affected and at-risk populations, as well as a commitment from all sectors of society. Taking advantage of their collective capacity for joint action, different sectors of society—business, education, church, NGOs and others—could coordinate sector-based plans for preventing infection and transmission.

The importance of testing,
education and communication

Tests are critical for epidemiological research and for developing adequate medical treatment. Thus, epidemiological surveillance must include large-scale testing in large urban centers and testing of essential workers, combined with effective contact tracing. The rapid identification of cases and contact tracing require decentralizing diagnostic services. community-level sero-surveillance can help identify and prioritize groups for vaccination and can guide and monitor vaccination programs.

It is imperative that the Nicaraguan people be informed of the true extent of the pandemic. Health education and objective information are vital to preventing and limiting the spread and impact of COVID-19. When the health sector is able to provide information on preventive measures, such as handwashing and social distancing, these become deeply rooted in public consciousness. Achieving this requires well-designed communication strategies. In Nicaragua, a successful precedent has already been established with medical and scientific organizations, which provide recommendations for dealing with the pandemic, despite the lack of a national strategy.

The scientific community must continue to provide evidence-based recommendations to inform the public and decision-makers of safety measures and their role in reducing the virus’ spread. It must also increase solid communication with the public, affiliating itself with primary media outlets and taking advantage of the social networks, data and all available on-line texts and information.

People, communities,
civil society and experts

Evidence shows that many deaths related to COVID-19 have occurred among the elderly and other vulnerable groups. According to the US Centers for Disease Control and Prevention (CDC), 80% of deaths in that country correspond to adults 65 years of age or older.

Any strategy to deal with COVID-19 must include increasing access to medical care and essential services for the elderly, as well as providing particular social and economic support to those who live in poverty, people with special needs and indigenous communities.

Civil society has an important role to play in the fight against COVID-19 locally and nationally. Local organizations are key to monitoring and assessing needs in the community, identifying vulnerable groups and improving communication. Organized citizens have had success providing assistance to vulnerable communities in Nicaragua. Concerted action is needed, using the synergy among different civil society organizations.

Globally, national academies and scientific societies provide advice to governments and society. Scientists and other experts are convened to collaborate in the timely collection and publication of data on the status of the outbreak and its social and economic consequences. Scientists and health experts in Nicaragua could form working groups focused on specific objectives and topics that require in-depth review. Recommendations must also be prepared for specific sectors of society, such as business, public transportation and the education sector.

Opening the economy and the
politicization of the pandemic

Opening the economy must be done gradually and must take into account the current state of the pandemic. Some governments justify their lenient approach to the pandemic by pointing to the need to save the economy. In Nicaragua, this approach together with avoiding any reduction in taxes, has led to putting the health and life of the majority of the population at enormous risk, while the political and economic interests of the governing elite benefit.

The immediate and long-term impact of COVID-19 will be particularly serious for the most disadvantaged, and the socioeconomic gap will increase. Re-opening the economy requires careful planning based on information on strategic economic sectors, such as tourism. Measures must be established for mitigating the devastating impact the pandemic may have on household financial security, while keeping transmission of the virus to a minimum. The government must design and adopt specific measures on a wide range of economic and social policies to achieve national objectives and guarantee both public health and human rights.

In many countries, the COVID-19 pandemic has been used for political and ideological ends. From the start, Nicaraguan authorities denied the true extent of the outbreak, organized massive public events and prohibited health workers from using protective equipment. It is increasingly clear that Nicaraguan leaders seek to adopt more dangerous political strategies, similar to the irresponsible medical populism approaches used with disastrous results in the United States, Brazil and the Philippines.

The SARS-CoV-2 virus respects neither borders nor political affiliations. Politicians must show leadership and make decisions based on scientific evidence, strengthening local capacity and giving budgetary priority to public health concerns. They must prioritize vaccines and medical treatment.

International cooperation is vital

Financial support and international cooperation are vital to implementing all these recommendations. Nicaragua will need to allocate funds in its national budget to provide the financial and human resources necessary for the national COVID-19 plan. Given the magnitude of the effort and the financial difficulties Nicaragua faces, however, this will also require coordinated support from the international donor community. It will also be necessary to seek international collaboration to address future waves of COVID-19.

There is an urgent need to promote safe, accessible vaccines against SARS-CoV-2 for their use around the world. The development of vaccines holds great potential for promoting international cooperation. Brazil, Argentina and Mexico, which have significant capacity in the area of vaccines and biotechnology, could cooperate with smaller countries like those of Central America to develop improved molecular diagnosis facilities and develop and reproduce vaccines.

Several low-cost vaccines against COVID-19 are making progress thanks to the actions of the Developing Country Vaccine Manufacturers Network (www.dcvmn.org). Through multilateral organizations and the Pan-American Health Organization (PAHO), Nicaragua could gain equitable access to vaccines and treatments for SARS-CoV-2.

Specific recommendations
for health workers

The SARS-CoV-2 pandemic has overwhelmed health care systems in many parts of the world, leading to hospital saturation and a reduction in care standards, which in turn has had negative consequences for health. There is acute physical and mental stress among health workers. In Nicaragua, medical associations have complained about the lack of personal protective equipment and have reported the deaths of dozens of health professionals.

Along those lines, health workers must regularly undergo diagnostic tests due to the high risk they run stemming from their exposure to the virus. Although systematic testing requires adequate laboratory capacity, which might not be available at all hospitals, they could prioritize high-risk hospitals and implement diagnostic alternatives. One is the molecular technology known as loop-mediated isothermal amplification (LAMP), which yields more rapid results, is low cost and shows sensitivity and specificity similar to the standard polymerase chain reaction (PCR) test.

Furthermore, it is necessary to guarantee sufficient health personnel and adequate personal protective equipment: N95 masks, facial protectors, surgical gowns and gloves. And there must be best practices in sanitizing and hygiene in hospitals and clinics.

Finally, health personnel must be guaranteed access to mental health services, which alleviate anxiety and stress. This intervention must be centered on preventive efforts to avoid adverse psychosocial consequences. Moreover, establishing clear guidelines, limiting working hours and avoiding excessive workloads are essential policies for ensuring patient care and stopping the pandemic.

An international audit is needed

An independent audit should be requested to assess and document handling of the pandemic in Nicaragua. This is essential for learning from the mistakes made and designing adequate policies for the future. A comprehensive evaluation of how the country prepared itself for the pandemic is needed. Likewise, an evaluation of the health care system is required as the basis for advance preparation for new waves of COVID-19 or other pandemics.

The WHO has offered to send a team of experts to assess Nicaragua’s health services, the epidemiological situation and all measures implemented since the pandemic began. We are calling for an independent international audit focusing on the actions implemented by government authorities over the previous eight months of the pandemic.

Title, headings and light editing by envío.

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