COVID-19 in Cuban Children and Adolescents. Fifth Report. Epidemiological Weeks from 7 to 17. from February 14 to May 1, 2021

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COVID-19 in Cuban children and adolescents. Fifth report. Epidemiological weeks from 7 to 17. From February 14 to May 1, 2021.

Luisa Íñiguez Rojas FLACSO-Cuba. University of Havana

Edgar Figueroa Fernández CEPDE-ONEI

Angel Miguel Germán Almeida IPK-MINSAP

Lissette del Rosario López González Head of the National Pediatrics Group of MINSAP

Lorenzo Somarriba López Head of Health Watch and of the Management Center, MINSAP, Cuba ÍNDICE

1.1. Evolution and general characteristics of COVID-19 in children and adolescents. Weeks from 7 to 17, 2021 | 03

1.2. Distribution by province of children and adolescents (from 0 to 18 years) confirmed with COVID-19 | 06

1.3. Distribution by municipality of children and adolescents (from 0 to 18 years) confirmed with COVID-19 | 08

1.4. Incidence of COVID-19 in children under one year | 12

Summary and reflections | 16

Bibliography | 18 The previous report, on the evolution of COVID-19 until epidemiological week 6, showed an increase of the virus’s transmission in the population under 18 years of age, and its relation with the rise in case detection in the population over 18 from the first epidemiological week of the current year. The descriptive cross-sectional study referred to in this report shows particularities of the propagation of CO- VID-19 from February 14 to May 1 (epidemiological weeks 7-17 of 2021), according to individual characteristics such as the sex and age of the infected children and adolescents, as well as the incidence by province and municipality, with an emphasis in the territorial spreading of cases. Due to its relevance, the fifth report on epidemiological characteristics and spatial dissemination of infection in Cuban children and adolescents includes a subsection on its incidence in children under one year of age. As in previous reports, the main sources for the study are the database of the Health Watch Office of the Minis- try of Public Health, other databases of the National Statistics and Information Office (ONEI), as well as cartographic resources from the GeoCuba Business Group. Again, the data used may have been modified or updated after the date of this report.

1.1 Evolution and general characteristics of COVID-19 in children and adolescents. Weeks from 7 to 17, 2021. As described in the fourth report in this series, from the last week of the year case detection in the country rose, which marked the beginning of a third epidemic wave, with an evident reflection in case detection in children and adolescents. In the eleven weeks referred to in this report, a new increase in detection is observed, with between more than 600 and up to 800 weekly cases recorded until week 12. From that moment, detection rises to more than 1,000 weekly cases. In correspondence with the increase in cases, the detection rates show values close to or above 3 in 10,000 children and adolescents until week 12, and rise to more than 4 in 10,000 in the following weeks of the study. Figure 1a. Thus, the evolution of case detection in children and adolescents throughout all epidemiological weeks since the beginning of the pandemic in Cuba, demonstrates that the most intense transmission of SARS-CoV-2 has occurred in what is considered a third epidemic wave. This intensified in the last five weeks of the study. Figure 1b. a) Cases Rate per 10 000 b) Cases 1200 6 1200 1000 5 1000 800 4 800 600 3 600 400 2 400 200 1 0 0 200 78910 11 12 13 14 15 16 17 0 Epidemiological weeks 12/2020 17/2021 Cases Rate per 10 000 Epidemiological weeks Figure 1. (a) Cuba. Confirmed cases and incidence rates of COVID-19 in children and adolescents (Weeks 7-17/2021) (b) Reported cases throughout the totality of epidemiological weeks (12/2020 to 17/2021). Source: Daily MINSAP reports. Database of the Health Watch Office.

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As in the previous report, imported cases, which totaled 97 between weeks 1 and 6, are not included in this increase. Between weeks 7 and 17, 37 imported cases were confirmed, which came mostly from Russia (17), and other countries like the United States (6), Mexico (5) and Spain (4). Imported cases had dropped to 3% between weeks 1 and 6. Between weeks 7 and 17, they represent 0.4% of confirmed cases, the majority of them being Cuban nationals residing in the country, concentrated in the provinces of La Habana, Ciego de Ávila and Camagüey. Figure 2. Between weeks 1 and 6, which showed a notable increase of transmission in the country, the detection of cases in children and adolescents was slightly more than 11% of total confirmed cases. In all of the weeks analyzed in this report, the proportion of cases from 0 to 18 years is above 12% and reaches values close to 15% in the last weeks of the study (Weeks 13, 14, 17). Figure 3.

Provinces % Pinar del Río 16 Artemisa La Habana 14 Mayabeque Matanzas 12 Villa Clara 10 Cienfuegos Sancti Spíritus 8 Ciego de Ávila Camagüey 6 Las Tunas Holguín 4 Granma Santiago de Cuba 2 Guantánamo 0 015 0215 0325 0 Cases 132 4 57689110 1112 3 14 15 16 17 Weeks 1-6 Weeks 7-17 Epidemiological weeks Figure 2.Imported COVID-19 cases detected in children Figure 3. Percentage of cases detected in children and and adolescents, by province. Weeks 1-6 and 7-17 of adolescents from the total confirmed cases in the country 2021. by epidemiological weeks (EW 1-7/2021). Source: Daily MINSAP reports. Database of the Health Watch Source: Daily MINSAP reports. Database of the Health Watch Office. Office.

Como regularidad de la epidemia se mantiene que las diferencias por sexo no son significativas. En el periodo que se analiza, se aprecia un incremento en la detección en el sexo femenino, entre las semanas 14 a la 16. Figure 4.

Cases 600 500 400 300 200 100 0 135724689110 1112 3 14 15 16 17 Epidemiological weeks Female Male Figure 4. COVID-19 cases in children and adolescents by sex and epidemiological weeks (7 to 17/2021). Source: Daily MINSAP reports. Database of the Health Watch Office.

The 12-to-18-years age group remains the one with more detected cases from the total in children and adolescents. Nevertheless, in the previous report this age group represented 49.29% of total cases from 0 to 18 years, a value that drops to 44.8% between weeks 7 and 17. This happens due to the increase of the percentage of detected cases in the 0-to-5-years age group, which rises from 24.40% to 27.78% in this period.

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Case detection in children from 0 to 5 years and from 6 to 11 remains, as in previous reports, below the proportion these groups represent of the country’s total 0-to-18-years population. Nevertheless, in the 0-to-5-years group, the increase in detected cases brings it closer to matching the proportion of the country’s total population of children and adolescents this group represents. The 12-to-18-years group, with 37.32% of this population, concentrates 44.8% of the cases, which maintains its overrepresentation in the incidence of COVID-19 in the country. Figure 5. a) % b) % 50 1200 40 1000 30 800 600 20 400 10 200 0 From From From 0 0 to 5 years 6 to 11 years 12 to 18 years 78910 11 12 13 14 15 16 17 Age range Epidemiological weeks % of cases from 0 to 18 years From 0 to 5 years % of population from 0 to 18 years From 6 to 11 years From 12 to 18 years Figure 5. (a) Cases by age groups as percentage of total cases from 0 to 18 years (b) Confirmed cases by age groups and epidemiological weeks. Source: Daily MINSAP reports. Database of the Health Watch Office.

A more detailed look to the 0-to-5-years group by weeks produces alarming information, when it reaches 30% of total detected cases in children and adolescents by week 17. This value is similar to the 30.73% this age group represents in the structure of the population from 0 to 18 years of age. Figure 6. Should this trend continue, the 0-to-5-years group may get to be overrepresented in the incidence of the epidemic in the country. And although the mass media have been making multiple appeals for several months to family and household members, unquestionably the ones responsible for the protection of children, it seems these have not had an impact so far in the reduction of the virus’s transmission in this age group. Such a trend would merit more detailed analyses of the behavior of household members, and perhaps even new measures for control and support of mothers or guardians with no other family support, single mothers, or mothers who continue to attend their workplaces.

Cases % 350 35 300 30 250 25 200 20 150 15 100 10 50 5 0 0 12345687 91011121314151617 Epidemiological weeks Cases from 0 to 5 years% of total from 0 to 18 years Exponential (% of total from 0 to 18 years) Figure 6. Cases in children from 0 to 5 years, percentage of the total from 0 to 18 years and growth trend. Source: Daily MINSAP reports. Database of the Health Watch Office.

An analysis of the totals demonstrates, as in previous reports, the similar distribution by sex and the increase in the number of confirmed cases. In particular, the 12-to-18-years and 0-to-5-years groups come to surpass the 6-to- 11-years group in the last weeks of the study. Figure 7.

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Date Date 14/02 14/02

26/02 26/02 10/03 10/03 22/03 22/03 03/04 03/04 15/04 15/04 27/04 27/04 0 2000 4000 6000 8000 10000 Cases 0 2000 4000 6000 8000 10000 Cases From 0 to 5 years From 6 to 11 years Female Male From 12 to 18 years Figure 7. Case totals in children and adolescents by sex and age groups. Source: Daily MINSAP reports. Database of the Health Watch Office.

As in weeks in previous reports, asymptomatic children and adolescents predominate, and within the symptomatic group, there’s a predominance of those with respiratory symptoms such as nasal congestion and secretion, sore throat, otitis and respiratory distress deriving in pneumonia. (López 2021). From week 7 to 17, 52% of local cases remained asymptomatic, similar to the proportion reported from week 1 to 6. 97% of imported cases confirmed were asymptomatic (37) and only one was symptomatic. The number of provinces reporting confirmed cases in travelers was reduced to eight, with La Habana still reporting the highest number of imported cases in children and adolescents with 12 out of the total 37, followed by Ciego de Ávila and Camagüey with 7 cases each.

1.2 Distribution by province of children and adolescents (from 0 to 18 years) confirmed with COVID-19 The detection of COVID-19 cases in children and adolescents maintains a high heterogeneity regarding politi- cal-administrative territories. The distribution of cases in the country’s provinces shows the highest concentration in the province of La Habana with 56.19% between weeks 7 and 17 of the current year, a higher proportion than was reported between weeks 1 and 6, when it represented 49% of total confirmed cases in the 0-to-18-years group. Figure 8.

Provinces 020140 60 80 100 120 140 60 Rate per 10 000 Pinar del Río Artemisa La Habana Mayabeque Matanzas Villa Clara Cienfuegos Sancti Spíritus Ciego de Ávila Camagüey Las Tunas Holguín Granma Santiago de Cuba Guantánamo Isla de la Juventud Cases 0 1000 2000 3000 4000 5000 6000 Cases Rate per 10 000 Figure 8. COVID-19 cases detected in children and adolescents by province. Rates per 10,000 children and adolescents (0 to 18 years, weeks from 7 to 17). Source: Daily MINSAP reports. Database of the Health Watch Office.

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The increased participation of the province of La Habana in the total detection of cases in children and adolescents in the country rises in the period being analyzed (weeks 7-17) and reaches 66.5% of the total in the last week. Figure 9. a) Cases b) % 1500 70 60 1000 50 40 30 500 20 10 0 0 7891011112 3 14 15 16 17 7891011112 3 14 15 16 17 Epidemiological weeks Epidemiological weeks La Habana Rest of the provinces Cuba total La Habana Rest of the provinces Figure 9. Cuba. Cases (a) and percentage (b) of confirmed cases in children and adolescents in La Habana and the rest of the provinces (14). Source: Daily MINSAP reports. Database of the Health Watch Office.

The high transmission in the province of La Habana remains. According to the index of territorial distribution by province (ITDP), La Habana reaches a value above 3, in severe disadvantage with respect to the country’s situation (=1). The province of Mayabeque is in a position of some disadvantage and the rest of the provinces are either at an advantage or balanced (Pinar del Río with 0.98 and Matanzas 0.90), or at a clear advantage (between 0.90 and 0.72) in relation to the country. Figure 10.

ITDP 3,50 3,00 2,50 2,00 1,50 1,00 Cuba 0,50 0 e o il a unas Áv Holguí n Granma Artemis a Matanzas Las T Villa Clara Camagüe y La Habana Cienfuegos Mayabequ Pinar del Rí Guantánamo Ciego de Sancti Spíritus

Provinces Santiago de Cuba Figure 10. ITDP. Index of territorial distribution by province of confirmed COVID-19 cases in children and adolescents: Relation between the population percentage out of the country total, divided by the case percentage out of the country total. Cuba=1. Source: Daily MINSAP reports. Database of the Health Watch Office.

The structure by age groups (=100) of detected cases in the pediatric population shows similar percentages by province, which are closer between the 0-to-5-years and 6-to-11-years groups, particularly in the western provinces of Artemisa and La Habana, Mayabeque, Matanzas and Villa Clara. The highest percentages are observed in the 12-to-18-years group in all provinces, ranging from a value of close to 55.31% of the total in the Province of Pinar del Río to slightly under 34.68% in Cienfuegos. In the majority of provinces, the 12-to-18-years specific rates are higher than those for the 0-to-18-years group, with the exception of the province of Cienfuegos, where the 0-to-5-years group is slightly higher. In the majority of provinces, the rate for the 0-to-5-years group is higher than for the 6-to-11-years group. Once again, the difference of transmission processes in the province of La Habana is stressed, with rates above 100 per 10,000 adolescents in both age groups. Figures 11a and 11b.

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a) Pinar del Río b) Provinces 60 Guantánamo Artemisa Pinar del Río 50 Artemisa Stgo. de Cuba 40 La Habana La Habana

30 Mayabeque Matanzas Granma 20 Mayabeque Villa Clara 10 Cienfuegos Sancti Spíritus Holguín Matanzas Ciego de Ávila Camagüey Las Tunas Las Tunas Villa Clara Holguín Granma Camagüey Cienfuegos Santiago de Cuba Guantánamo Rate per Ciego de Ávila Sancti Spíritus 0120 40 60 80 00 120 1401160 80 10 000 From 0 to 5 years From 6 to 11 years From 0 to 5 years From 6 to 11 years From 12 to 18 years From 12 to 18 years Figure 11. (a) Distribution of confirmed cases by province and age groups. (b) specific rates from 0 to 18 years per 10,000 people in this age group. Source: Daily MINSAP reports. Database of the Health Watch Office.

1.3 Distribution by municipality of children and adolescents (from 0 to 18 years) confirmed with COVID-19 In the period under analysis in this report, the number of municipalities that confirmed cases in children and adolescents by epidemiological weeks remained above eighty; approximately half of the total municipalities in the country. Higher values of confirmed cases were also reached in the majority of epidemiological weeks. In spite of the rise in cases and the notable territorial dispersion from the first week of the present year, ten municipalities did not record any cases between weeks 7 and 17. These are located in the central province of Villa Clara (1), the eastern-central province of Camagüey (2) and the eastern provinces of Las Tunas (3), Granma (1) and Guantánamo (3). Between week 12 of 2020, when the first detection was made, and week 17 of 2021, six municipalities had not confirmed cases in children and adolescents. Figure 12. Three of those municipalities are among the most rural and least populated in the country, ranging from less than 1,000 to little over 2,000 children and adolescents (Sierra de Cubitas and Najasa in the province of Cama- güey and Yateras in the province of Guantánamo). Two others are located in the province of Las Tunas, with about 5,000 children and adolescents, and the last one is Media Luna, located in the province of Granma, with close to 3,000.

Number of municipalities 180 160 140 120 100 80 60 40 20 0 182 3 4 5 6 7 91011121314151617 Epidemiological weeks Con rming cases Total Con rming for the rst time Figure 12. Number of municipalities by province and Isla de la Juventud special municipality, according to case detection between weeks 7-17. Source: Daily MINSAP reports. Database of the Health Watch Office.

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From week 1 to 6/2021, close to 80% of municipalities reported cases in children and adolescents (133). The notable rise in detection in the country between weeks 7 and 17 was joined by a wider dispersion by municipalities, with 157 municipalities (93.45% of the total) reporting cases. The most notable increases occurred in municipalities from the provinces of La Habana, Matanzas and Granma, and particularly in those where provincial capitals and second cities are located. Showing the highest numbers, over 400 confirmed cases, are six municipalities, five of them in the province of La Habana (Arroyo Naranjo, Diez de Octubre, San Miguel del Padrón, Habana Vieja and Centro Habana) and the Santiago de Cuba municipality in the province of the same name. The distribution of cases by municipality shows that these are concentrated in fourteen from the country’s capital and two containing provincial capitals in Pinar del Río and Granma (Bayamo). Also with a very high number of cases are four other municipalities with provincial capitals, two with second cities (Cárdenas and Palma Soriano) and the municipality of Regla in the country’s capital. Little over 70% of the 119 municipalities with the lowest numbers of infections correspond with those having the smallest amount of population from 0 to 18 years in the country, with the exception of those with provincial capitals such as Villa Clara, Ciego de Ávila and Las Tunas. Figure 13, Map 1

Cases 50 40 30 20 10 0 Municipalities WEST EAST Weeks 1 to 6 Weeks 7 to 17 Figure 13. COVID-19 cases in children and adolescents by municipalities in weeks 1 to 6 and weeks 7 to 17 of 2021. Each bar represents a municipality. Source: Daily MINSAP reports. Database of the Health Watch Office.

Map 1. Cuba. Conﬁrmed COVID-19 cases in children and adolescents by municipality. Weeks 7 to 17 (from February 14 to May 1, 2021).

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048 kilometers

Confirmed cases 422 to 736 (6) 217 to 389 (2) Provincial capitals 91 to 172 (6) 46 to 86 (14) 2 to 41 (113) 1 (6)

No cases (11) 075 100 kilometers Fuente: Daily MINSAP reports. https://salud.msp.gob.cu/ Digital Cartographic base 1:1 000 000 Geo Cuba. Author: Luisa Íñiguez Rojas, FLACSO, University of Havana

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In correspondence with the territorial heterogeneity of confirmed cases and the differences in the amount of population from 0 to 18 years, the total incidence rates show variations by municipalities that range from less than 1 in 1,000 to close to 30 in 1,000. The specific rate of COVID-19 per every 1,000 people in the 0-to-18-years population group stresses the territorial heterogeneity of the evolution of the pandemic in the country, as has been described in previous reports, with the most intense transmission in the western region and within it in the province of La Habana, its capital. It should be pointed out that several municipalities in the province of Matanzas, with very low incidence rates between weeks 1 and 6 underwent a notable increase in case detection, in correspondence with the rising number of confirmed cases in that territory among the population from 0 to 18 years in the last weeks of the study. In the province of Matanzas, municipalities with around 500 children and adolescents, a relatively smaller size, and rates under 1 in 1,000 between weeks 1 and 6, are showing high rates that rise to values close to or above 4 in 1,000 between weeks 7 and 17. This is the case in Los Arabos, Perico and Pedro Betancourt, which reach a rate of 8 in 1,000. Also with high incidence rates between weeks 7 and 17 are municipalities containing the most populous cities and the provincial capital, with more than 30,000 children and adolescents, although with less notable increases in comparison with the values obtained between weeks 1 and 6. Figure 14, Map 2.

Rate per 1000 40

0 Municipalities WEST EAST Weeks 1 to 6 Weeks 7 to 17 Figure 14. Incidence rates of COVID-19 per 1000 children and adolescents by municipality in weeks 1 to 6 and weeks 7 to 17 of 2021. Each bar represents a municipality. Source: Daily MINSAP reports. Database of the Health Watch Office.

Map 2. Cuba. Accumulated COVID-19 rate in children and adolescents by municipality. Weeks 7 to 17 (from February 14 to May 1, 2021).

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048 kilometers

Rate per 1000 inhabitants 29.93 to 29.94 (1) 10.48 to 19.55 (12) 5.08 to 9.61 (13) Provincial capitals 2 to 4.7 (47) 0.96 to 1.93 (40) 0.07 to 0.94 (44) No cases (11) 075 100 kilometers Fuente: Daily MINSAP reports. https://salud.msp.gob.cu/ Digital Cartographic base 1:1 000 000 Geo Cuba. Author: Luisa Íñiguez Rojas, FLACSO, University of Havana

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The index of territorial distribution by municipality shows the severity of transmission in Habana Vieja, with a value of 7 at a disadvantage according to the relation between the proportion of its cases and its population from 0 to 18 years with respect to the other municipalities in the country. Figure 15.

ITDM 8 Habana Vieja 7.07 7 6 5 4 3 2 1 Cuba 0 1 8 18 28 38 48 58 68 78 88 98 108 118 128 138 148 158 168 Municipalities (168) Figure 15. ITDM. Index of territorial distribution by municipality of confirmed COVID-19 cases in children and adolescents. Cuba=1. Source: Daily MINSAP reports. Database of the Health Watch Office.

In relation to the country, fifteen of the sixteen municipalities with the sharpest disadvantage (values close to or above 2) belong to the province of La Habana and one of them (Pedro Betancourt) to the province of Matanzas, with a sharp increase of incidence in the last weeks of the period between weeks 7 and 17. Figure 16.

Figure 16. ITDM. Index of territorial distribution by municipalities with the greatest disadvantages in case confirmation in children and adolescents compared with the country Cuba=1. MUNICIPALITY ITDM MUNICIPALITY ITDM Habana Vieja 7.07 Marianao 2.65

Regla 4.62 Plaza 2.64

Centro Habana 4.09 Guanabacoa 2.52

Arroyo 4.03 Habana del Este 2.51

Cerro 3.91 Boyeros 2.48

Cotorro 3.55 Lisa 2.27

Diez de Octubre 3.48 P. Betancourt 2.16

San Miguel del Padrón 3.06 Playa 1.97

Source: Daily MINSAP reports. Database of the Health Watch Office.

The distribution of cases according population size of the municipalities shows that nearly 70% of the total detected cases were recorded in the most populous municipalities (those having more than 100,000 inhabitants), which are overrepresented in the epidemic in the country. These municipalities are at a clear disadvantage in comparison with the rest of municipalities according to their size, which are underrepresented, and where the percentage of their population from 0 to 18 years with respect to the total percentage of the country, is higher than the percentage of cases detected in them. These data, though general, suggest a direct relation between the amount of population of children and adolescents and a higher spreading of infection. This relationship pattern would be expected, according to a greater density of social relations, especially in adolescents, and in household members or third persons in the case of the 0-to5-years group. Figure 17.

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% 80

0 More From 50 000 From 30 000 Less than 100 000 to 100 000 to 50 000 than 30 000 Amount of population % of Population from 0 to 18 years of the total % of Cases from 0 to 18 years of the total Figure 17. Distribution of confirmed cases by aggregate of municipalities by population size. Weeks 7 to 17 of 2021. Source: Daily MINSAP reports. Database of the Health Watch Office.

1.4 Incidence of COVID-19 in children under one year The indications of a rise in confirmed cases in the population under one year of age set forth in the previous report are confirmed in the period being studied. Between weeks 7 and 17, the confirmed cases rise notably, particularly from week 8. Therefore, there’s a rise in weekly incidence rates, expressed in cases per 10,000 children under one year. Figure 18.

Rate per Cases 10 000 70 7 60 6 50 5 40 4 30 3 20 2 10 1 0 0 12345687 91011121314151617 Epidemiological weeks Conrmed cases Rate per 10 000 Figure 18. Confirmed cases and incidence rates in children under one year by epidemiological week. Weeks from 1 to 17. Source: Daily MINSAP reports. Database of the Health Watch Office.

The province of La Habana accumulates the highest number of confirmed cases in children under one year, and it increases their participation in the total number of confirmed cases. With approximately 22% of the population in this age group in the country, it concentrates 53% of confirmed cases. Figure 19. The municipal dispersion of COVID-19 incidence in this age group is more intense than in the 0-to-18-years group. Between weeks 1 and 6, 50 municipalities (29.76% of the total) confirmed cases, and this rises to 94 municipalities (55.95% of the total) between weeks 7 and 17. 34 of them confirmed only one case. 74 municipalities did not confirm cases in the period. The total number of municipalities confirming cases each week remains between 25 and 30, with the exception of week 7, when less than 20 confirmed cases, and of the last weeks of the period, when more than 30 municipalities confirmed cases in children under one year. From the first epidemiological week of the year until week 17, ending on May 1, 67 municipalities had not reported any cases in children under one year. Figure 20.

-12- LA COVID-19 EN NIÑOS Y ADOLESCENTES CUBANOS. QUINTO REPORTE. SEMANAS EPIDEMIOLÓGICAS.... a) Provinces b) % Pinar del Río 90 Artemisa La Habana 80 Mayabeque 70 Matanzas Villa Clara 60 Cienfuegos 50 Sancti Spíritus Ciego de Ávila 40 Camagüey 30 Las Tunas 20 Holguín Granma 10 Santiago de Cuba 0 Guantánamo 182 3 4 5 6 7 91011112 3 14 15 16 17 Isla de la Juventud Epidemiological weeks 0150 00 150 2003250 00 Cases La Habana Rest of the provinces Figure 19. (a) Confirmed cases in children under one year by province. Weeks 1 to 17. (b) Confirmed cases in the province of La Habana and in the rest of the provinces, as percentage of total confirmed cases from 0 to 18 years. Source: Daily MINSAP reports. Database of the Health Watch Office.

Number of municipalities 35 30 25 20 15 10 5 0 78910 11 12 13 14 15 16 17 Epidemiological weeks With one case With two or more cases Figure 20. Number of municipalities confirming cases in children under one year by epidemiological week. Source: Daily MINSAP reports. Database of the Health Watch Office.

The distribution of cases by municipality, compared with the totals of weeks 1 to 6, shows both the increase in cases in weeks 7 to 17, and the growing number of municipalities with confirmations. The concentration of cases in the municipalities of the province of La Habana is noticeable, followed by those where the provincial capitals are located in the provinces of Santiago de Cuba and Pinar del Río (same name) and Granma (Bayamo). The highest figures were reached by the municipalities of Arroyo Naranjo, Boyeros and San Miguel del Pa- drón, in all cases coinciding with those with the highest population under one year from the province’s total. Figure 21, Map 3.

Casos 50 40 30 20 10 0 Municipios OCCIDENTE ORIENTE Semanas de la 1 a la 6 Semanas de la 7 a la 17 Figure 21. Distribution of confirmed cases in children under one year. Weeks 1 to 6 and weeks 7 to 17. Each bar represents a municipality. Source: Daily MINSAP reports. Database of the Health Watch Office.

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Map 3. Cuba. Conﬁrmed COVID-19 cases in children under one year, by municipality. Weeks 7 to 17 (from February 14 to May 1, 2021).

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048 kilometers

Cases 20 to 38 (5) 10 to 19 (13) Provincial capitals 6 to 9 (10) 2 to 5 (32) 1 (34) No cases (74) 075 100 kilometers

Fuente: Daily MINSAP reports. https://salud.msp.gob.cu/ Digital Cartographic base 1:1 000 000 Geo Cuba. Author: Luisa Íñiguez Rojas, FLACSO, University of Havana

The relation between the confirmed cases in children under one year between weeks 1 and 6 (from January 3 to February 13) and 7 to 17 (from February 14 to May 1, 2021), shows the notable increase in transmission in the majority of municipalities in the country, Map 4.

Map 4. Cuba. Municipal distribution of conﬁrmed COVID-19 cases in children under one year. Weeks 1 to 6 and 7 to 17.

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048 kilometers

Confirmed cases (children under one year) 29 14.5 2.9

Weeks from 1 to 6 Weeks from 7 to 17 075 100 kilometers

Fuente: Daily MINSAP reports. https://salud.msp.gob.cu/ Digital Cartographic base 1:1 000 000 Geo Cuba. Author: Luisa Íñiguez Rojas, FLACSO, University of Havana

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The index of municipal distribution of confirmed cases in children under one year shows 37 municipalities at a disadvantage in relation to the incidence of the disease in the pediatric population. 11 municipalities are in a balance, with values around one (Cuba). Of the sixteen municipalities with a more unfavorable index of territorial distribution, eleven belong to the province of La Habana, three to Mayabeque and two to Matanzas, all of them in the western region of the country. The greatest disadvantage of the municipality of Habana Vieja among the country’s municipalities is repeated, with a distribution index higher than 5. Six other municipalities from the center or the periphery of the province of La Habana show values close to or above 3, as well as three municipalities from the province of Mayabeque. These values indicate the severity of transmission, according to the relation between the proportions of cases and population of children under one year in relation to the country. Figures 22 and 23.

Figure 22. ITDM. Index of territorial distribution by municipalities with the greatest disadvantages in case confirmation in children under one year compared with the country Cuba=1. MUNICIPALITY ITDM MUNICIPALITY ITDM Habana Vieja 5.28 Marianao 2.71 San Miguel del Padrón 3.81 Regla 2.64 Plaza de la Revolución 3.77 Jovellanos 2.61 Güines 3.55 Diez de Octubre 2.31 Batabanó 3.22 Habana del Este 2.29 Arroyo Naranjo 3.21 Jagüey Grande 2.27 Centro Habana 3.06 La Lisa 2.16 Boyeros 2.78 Cerro 2.14 San Nicolás 2.76 Playa 2.13 Source: Daily MINSAP reports. Database of the Health Watch Office.

ITDM 6 Habana Vieja 5.80 5 4 3 2 1 Cuba 0 1 8 18 28 38 48 58 68 78 88 98 108 118 128 138 148 158 168 Municipalities (168) Figure 23. ITDM. Index of territorial distribution by municipality of confirmed cases in children under one year. Cuba=1. Source: Daily MINSAP reports. Database of the Health Watch Office.

-15- Summary and reflections Between epidemiological weeks 1 to 6 of 2021, which go from January 3 to February 13, 9,622 positive cases were confirmed, with a notable increase in the intensity of transmission and territorial spreading of COVID-19 in Cuban children and adolescents. This is reinforced between weeks 7 and 17, the ones referred to in this report, and in particular between weeks 13 and 17, with a new increase in detection. The operational protocols in the pediatric sphere are set apart for being dialectic and aimed at reaching the highest level of detail in providing science-based care. The strength of these protocols has allowed 94% of all detected children and adolescents to leave healthcare centers satisfactorily. In this period, two female patients in pediatric ages were reported deceased. The increase of participation of pediatric cases in the total number of cases detected in the epidemiological weeks being studied, and the weekly incidence (cases per 100,000 people) is observable in all age groups, with the highest figures in the 12-to-18-years group. The percentage of confirmed children between 0 and 5 years from the total from 0 to 18 increases, and in the last weeks of the period under analysis, it gets to be similar to the percentage the group represents in the age structure of the population from 0 to 18 years. 5.6% of diagnosed cases were children in breastfeeding age. These figures indicate the severity of infections in this group, and particularly in children under one year, an unusual fact which requires more detailed analyses and a revision of the prevention and control actions executed so far. The above entails the urgent need to reinforce the personalized social message to each family on the importance of protecting minors with absolute responsibility and without carelessness. As in previous reports, no significant differences by sex have been reported, only a slight increase of female cases in the last weeks of the period. 50.3% of detected cases had contact with positive cases inside the household as the source of infection, which ratifies the pressing need to reinforce precautions inside the homes. The predominance of asymptomatic cases con- tinues in approximately half of detected cases. This figure is lower than that of the first epidemic wave, when 70% of cases evolved asymptomatically. The progression of transmission in children and adolescents in the country maintains a heterogeneous territorial distribution. The higher intensity of infection occurs in the western region of the country, in its capital, provincial capitals and second cities. The province of La Habana increases its participation in case detection in children and adolescents, significantly above the proportion of population in this age group. Although the municipalities of San Miguel del Padrón and Arroyo Naranjo present the highest number of cases, it is the municipality of Habana Vieja that shows the highest severity of infection in this period according to the rates and indexes of territorial distribution by municipality (ITDM) in relation to the country, both in the population from 0 to 18 years and in children under one year. The rise in detection in municipalities of the province of Matanzas corresponds with the more recent outbreaks in the general population that have occurred in these territories, associated with the circulation of a new strain of the coronavirus (identified in South Africa). There is also a high, sustained transmission in the municipalities of Santiago de Cuba, in the province of the same name, and Bayamo, in the province of Granma. Among the factors involved in the increase of cases in pediatric ages detected in the period being analyzed, are those generally related with the general increase of cases in the country, as well as those having a more direct incidence in transmission among children and adolescents.

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In the first case, some elements pointed out have been violations in the measures for the restriction of mobility of the population between provinces, municipalities and within them; failures to observe protocols in healthcare centers; failings on the community level of the bodies involved in controlling the epidemic; a reduction of infection risk perception; and a gradual increase of SARS-CoV-2 variants from late December 2020, identified as highly con- tagious, with easier and faster spreading than the original variant (Cubadebate, 2021a). In the period that corresponds to this report, variant D614G, which circulated since the beginning of the epidemic and which was already considered more transmissible in comparison with the original Wuhan strain, has been replaced by the Beta variant (B.1,351) initially detected in South Africa. This variant started to prevail until it became predominant in the country in the month of April (Cubadebate, 2021b). It is probable that genetic variants of the virus modify the clinical evolution of the infection. The reduction of the perception of risk by the population is a direct factor that would explain the sustained increase in confirmed cases in the population from 12 to 18 years, associated to the prolonged time of limitation of physical contact and of readjustment of daily life, which are particularly difficult for adolescents and young people. In all probability, this is the group that more carelessly applies protective measures. If it is logical to assume that families have more difficulties in controlling the mobility and the use of means that protect from infection in the case of their adolescent sons and daughters, this would not be so in the case of younger children. It is evident in the report that the 0-to-5-years group, with a lower probability of being exposed to the virus, increases its participation among cases in pediatric ages, with values approaching the proportion of the population in these ages, and particularly in the case of children under one year, where infection is absolutely dependent on the adults. The sustained priority given by various media to the communication of figures and to alerts regarding the increase of cases in pediatric ages, the repeated alerts about the need to reinforce precautions, and information on the possible consequences for the mental and physical health of infected children and adolescents, are in contrast with the sustained rise in detected cases. This justifies the need to rethink focalized strategies for information and intervention, according to the living context of children and adolescents. The progress of studies that are specific and have a multidisciplinary approach could lay the foundations for these purposes.

July 2021 Fifth report by the Project “COVID-19 in children and adolescents in Cuba. Social sciences and health issues”. FLACSO-Cuba. University of Havana

-17- Bibliography Unicef. La COVID-19 en niños y adolescentes cubanos. Cuarto reporte: https://www.unicef.org/cuba/documents/ la-covid19-en-niños-y-adolescentes-cubanos-cuarto-reporte Oficina Nacional de Estadísticas e Información (ONEI). (2017): Nomenclador de Asentamientos Humanos. Censo de Población y Viviendas, 2012. La Habana: ONEI. Oficina Nacional de Estadísticas e Información (ONEI). (2021): Poblacíon por grupos de edades provincias y municipios. La Habana: ONEI. Oficina Nacional de Estadísticas e Información (ONEI) (2020): Indicadores Demográficos de Cuba y sus territorios. La Habana: ONEI. Unicef. (agosto 2020): Obtenido de UNICEF Data: Monitoring the situation on children and women: https://data. unicef.org/resources/resource-topic/covid-19/ Cubadebate (a). Cuba lamenta primer fallecido en edad pediátrica con COVID-19 y 959 nuevos casos. http://www.cubadebate.cu/noticias/2021/04/11/cuba-reporta-primer-fallecido-en-edad-pediatrica-con-covid-19-y-959-nuevos-casos/ Cubadebate (b). Mesa: Situación epidemiológica, nuevas cepas y efectividad de las vacunas Ministro de Salud Pública Presidente de BioCubaFarma, Directora de Investigación, Diagnóstico y Referencia del IPK Ante nuevas variantes del SARS-CoV-2. 8 abril 2021 http://mesaredonda.cubadebate.cu/mesa-redonda/2021/04/08/ ante-nuevas-variantes-del-sars-cov-2-cual-es-la-situacion-en-cuba-y-la-potencial-efectividad-de-las-vacunas- cubanas-video/ Cubadebate. (c) Cuba: Eficacia de los candidatos vacunales y nuevas cepas del SARS-CoV-2 . http://www.cubadebate. cu/noticias/2021/07/19/cuba-eficacia-de-los-candidatos-vacunales-y-nuevas-cepas-del-sars-cov-2-video/#ane- xo-1583735 Confirman presencia de cepa sudafricana y de California en Matanzas. https://www.matanceros.gob.cu/en/actua- lidad/noticias/sobre-el-coronavirus/695-noticias-sobre-covid/9305-confirman-presencia-de-cepa-sudafricana-y-de-california-en-matanzas 9 abril 2021

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