01 Pan American Journal Current topic of Public Health 02 03 04 05 06 SARS-CoV-2 outbreak on the Caribbean islands of the 07 08 Dutch Kingdom: a unique challenge 09 10 11 1 2 3 4 Priscilla Maria , Lung Jeung , Ashley Duits and Jamiu Busari 12 13 14 15 Suggested citation Maria PA, Jeung L, Duits AJ and Busari JO. SARS-CoV-2 outbreak on the Caribbean islands of the Dutch Kingdom: a unique 16 challenge. Rev Panam Salud Publica. 2020;44:e91 https://doi.org/10.26633/RPSP.2020.91 17 18 19 20 ABSTRACT As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic progresses, countries are 21 depending on one another to acquire knowledge regarding effective measures to contain the virus. Public 22 health measures to suppress transmissions have proven successful in Singapore, Hong Kong and Taiwan. 23 Implementing and adhering to these interventions is challenging, with governments struggling to find a bal- 24 ance between necessary mitigation and suppression strategies, and interruptions of social-economic activities. 25 While large high-income countries are struggling to keep their health systems and economies moving forward, 26 small island developing states are facing even more significant challenges. Many Caribbean islands, including 27 the six islands within the Dutch Kingdom, have been quick to implement stringent public health measures, yet 28 they are facing unique challenges. 29 30 Keywords Coronavirus; pandemics; West Indies; Caribbean Region; Americas. 31 32 33 34 35 As the severe acute respiratory syndrome coronavirus 2 THE SITUATION THUS FAR 36 (SARS-CoV-2) pandemic progresses, countries are depend- 37 ing on one another to acquire knowledge regarding effective As soon as the first local cases of coronavirus disease 2019 38 measures to contain the virus. Public health measures to sup- (COVID-19) were reported, the governments of the islands 39 press transmissions have proven successful in Singapore, were quick to take decisive measures, choosing to close their 40 Hong Kong and Taiwan.(1,2) Implementing and adhering airspace and implement the necessary mitigation measures.(3) 41 to these interventions is challenging, with governments As of now Bonaire has 2 positive cases (308 tested), Saba 3 pos- 42 struggling to find a balance between necessary mitigation itive cases (125 tested), and Statia 2 positive cases (17 tested). 43 and suppression strategies, and interruptions of social-eco- (4-5) All three pre-emptively closed off their borders, with the 44 th th st nomic activities. While large high-income countries (HIC) first case reported on April 16 , April 12 and March 31 respec- 45 are struggling to keep their health systems and economies tively. Curaçao, as of now, has 21 confirmed cases (1100 tested, 46 th moving forward, small island developing States (SIDS) are 1 by death) since the first reported case on March 12 with most 47 facing even more significant challenges. Many Caribbean of these “imported cases” involving people who were visiting 48 islands, including the six islands within the Dutch King- or residents who arrived from abroad. In both St. Martin and 49 dom, have been quick to implement stringent public health Aruba, however, at one point the virus was spreading locally 50 measures. Nevertheless, with the populations on the islands within the community with 77 (450 tested, 15 deaths) and 101 51 ranging from only 1,900 to 160,000, they are facing unique cases (2150 tested, 3 deaths) respectively registered since the first 52 st th challenges. reported cases on the 1 and 13 of March 2020.(7-8) (Table 1) 53 54 55 56 1 Amsterdam UMC, Amsterdam, Netherlands * [email protected] 3 Red Cross Blood Bank Foundation Curaçao, Willemstad, Curaçao 57 2 Radboud UMC, Nijmegen, Netherlands 4 Dr Horacio E Oduber Hospital, Oranjestad, Aruba 58 59 This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 IGO License, which permits use, distribution, and reproduction in any medium, provided the 60 original work is properly cited. No modifications or commercial use of this article are permitted. In any reproduction of this article there should not be any suggestion that PAHO or this article endorse any specific organization or products. The use of the PAHO logo is not permitted. This notice should be preserved along with the article’s original URL. N61 Rev Panam Salud Publica 44, 2020 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2020.91 1 Current topic Maria et al. • COVID-19 on the Caribbean small island developing states TABLE 1. Demographics of the six islands (with the Netherlands for reference) and impact of COVID-19 as of June 8 Aruba Bonaire Curaçao St. Martin Statia (St. Saba The Netherlands Eustatius) Area 180km2 288km2 444km2 34km2 21km2 13km2 41,865km2 Population 112,309† 20,104† 158,665† 41,486‡ 3,138† 1,915† 17,424,978 (10) (10) (10) (10) (10) (10) (10) GDP 1.862 billion USD 434 million USD 2.841 billion USD 894 million USD 100 million USD 48 million USD 913.658 billion USD (2017) (2016) (2017) (2017) (20168) (20168) (2018) (10) (28) (10) (10) (28) (28) (10) GDP per capita 16,778 USD 22,500 USD 17,751 USD 22,047 USD 26,100 USD 24,200 USD 53,024 USD (2017) (2016) (2017) (2017) (2016) (2016) (2017) (9) (28) (9) (9) (28) (28) (10) World Bank High-Income - High-Income High-Income - - High-income Classification Country status Autonomous country Special Autonomous Autonomous Special Special Autonomous country within the Dutch municipality within country within the country within the municipality within municipality within within the Dutch Kingdom (1986) the Netherlands Dutch Kingdom Dutch Kingdom the Netherlands the Netherlands Kingdom (2010) (2010)* (2010)* (2010) (2010) First reported March 13th April 16th March 12th March 1st March 31st April 12th February 27th case COVID-19 Current confirmed 101 2 21 77 2 3 47,739 cases as of June 8th Amount of people 2150 308 Not available 450 308 125 N/A tested Deaths as of June 3 0 1 15 0 0 6,016 8th †Based on 2019 estimates. ‡Based on 2016 estimates. *After the dissolution of the Netherlands Antilles, Curaçao and St. Martin remained within a monetary union retaining one Central Bank. The local governments took action before local transmission external support to alleviate their scarcity of employees. The of the virus was confirmed on the islands and the chosen mea- Dutch government has, however, prepared a navy ship with 30 sures can be considered adequate for the benefit of public health ICU beds for the islands. Twelve ICU unit beds, including ven- and also courageous as the entire economy would be shut tilators, personal protective equipment (PPE), and personnel down as a result. In contrast, during this same period soccer arrived in St. Martin in March, whereas the other islands will matches were still being played in Spain and Italy, and carnival receive aid later if needed. was celebrated in the Netherlands despite news that the virus The minister of Health of Curaçao announced that the Neth- was present in Europe. This dilemma between public health erlands would be financing the wages of 102 medical personnel measures and the economy was observed in most countries, from the U.S. and Cuba if Curaçao financed their stay.(12) followed by unprecedented repercussions. The islands were The question is, how big of a burden will the disease be on the no exceptions in this as the restrictive measures, while effec- islands if left unmitigated? The Imperial College reports a strong tive, also led to much chagrin among the population, requiring correlation between the gross domestic product (GDP) per cap- repeated press conferences by the local governments to explain ita of a country and its population’s underlying demography. the need for these measures. (10) They argue that HICs tend to have a bigger proportion of the population who are above 65 years of age and therefore, SCARCITY IN HEALTHCARE EQUIPMENT AND have a higher incidence of severe disease and hospitalization. PERSONNEL Although Aruba, Curaçao and St. Martin are officially classified as HIC, there is a big difference between their respective GDP The overriding aim is to ensure that the local healthcare capac- per capita (16,778 USD, 17751 USD, and 22,047 USD) and, for ity is not overburdened and specifically that there are never more example other HICs such as the Netherlands (53,024 USD) or patients that require ventilatory support than there are suitable Italy (34,483 USD).(13,14) Despite this gap, between 13 to 17% intensive care unit (ICU) beds.(9) On average for Europe, Asia of the population on each of these islands is >65 years old, only and the U.S., the number of these beds are respectively 0.12, 0.04 slightly lower than the Netherlands (19%) and Italy (23%). and 0.28 per 1,000 people, with considerable variations even (15-19) between regions with the same World Bank classification. Ger- Based on current data, older adults who have severe under- many, for example, has 6.9 times more ICU beds than Portugal. lying medical conditions are at a higher risk for severe illness (10,11) In comparison, on Curaçao, Aruba, Bonaire, and St. Mar- from COVID-19.(20,21) The most recent census on Curaçao tin there are respectively 0.05, 0.12, 0.15, and 0.073 beds per 1,000 (2011) revealed that at least 27.4% of the residents have one or people. The two smaller islands have no ICU. more chronic diseases and/or disorders.(22) According to the While flattening the curve is the goal, many countries are also WHO STEPwise Approach Survey (STEPS) conducted in Aruba, increasing their ICU capacity.