COVID-19 in Cuban children and adolescents. Second report. Epidemiological weeks 12 to 30. July 2020.

Luisa Iñiguez Rojas. FLACSO-. University of .

Edgar Figueroa Fernández. CEPDE-ONEI.

Laura Almora Andarcio. CIPS. CITMA.

Angel Miguel Germán Almeida. IPK. Ministry of Health.

Antonio Herrada Hidalgo. FLACSO-Cuba. University of Havana.

Lorenzo Somarriba López. Director. Centre for Health Surveillance. Ministerial Management Centre. Ministry of Health. CONTENT

1.1. Characterization of children and adolescents diagnosed with COVID-19 (by sex and age) | 03

1.2. Provincial distribution of children and adolescents (aged 0-18 years) confirmed with COVID-19 | 06

1.3. Municipal distribution of children and adolescents (aged 0-18 years) confirmed with COVID-19 | 08

1.4. Distribution of children and adolescents (aged 0-18 years) confirmed with COVID-19 by human settlements | 10

1.5. Spatial clusters and sources of transmission | 13

General conclusions | 16

References | 17 The first report (June, 2020) on the epidemiological COVID-19 in children and adolescents in Cuba and characteristics and spatiality of COVID-19 in Cuban its territories. children and adolescents included 223 positive cases between March 21 and May 30 (Íñiguez Rojas, et al., 1.1. Characterization of children 2020). After 126 days of the epidemic’s evolution in and adolescents diagnosed with Cuba, 278 children and adolescents had been confir- the COVID-19 (by sex, age). med with COVID-19. Four of them were li- The evolution in epidemiological weeks 12 to 30 shows ving abroad, two were tourists and one was a Cuban an increase in notifications from week 13 onwards. resident who had returned to the country with her The maximum number of confirmed cases is reached mother. in weeks 15 (55), 16 (34) and 17 (39). In the following At the time of writing this report, a number of stu- weeks, notifications are reduced, with slight increases dies have been published around the world discus- in weeks 23 and 27, as shown in Figure 1. The percen- sing manifestations and possible effects on children tage representation (Figure 2) of children and adoles- (UNICEF, 2020) (LunaA-Bazaldua & Pushparatnam, cents of the total number of confirmed persons in the 2020) (CDC, 2020) (Ballarini, Arriola, Santagapita, & country varies from less than 5 % to more than 40 % of Bonnin, 2020). Some relevant, and sometimes contra- the total in week 27. dictory, points in the debate focused on the relatively Cases low confirmation of cases in children and adolescents 300 with COVID-19 in relation to the adult population, or the under-detection of cases due to slight or inexistent 250 symptoms, or viral load. Other working hypotheses 200 related to lower susceptibility to infection, the ability 150 to transmit the virus, and the low rates of hospitaliza- tion and death of children compared to adults. 100 This second report follows up on the pandemic, 50 including the findings of the first one, and inclu- 0 des the epidemiological and spatial characteristics 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 between May 31 and July 25 (epidemiological wee- Epidemiological weeks ks 23 to 30)1 to provide an evolutionary picture of Cases per week Cumulative cases Figure 1. COVID-19 in children and adolescents by date of 1 Generally, in order to analyse the behaviour and evolution of confirmation (cases per week and cumulative). diseases, especially communicable ones, epidemiological wee- Source: Ministry of Health’s daily briefings. Department of ks that follow an international calendar are used. Health Surveillance’s Database.

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Percentage Cases 50 160 43.5 140 40 120 100 30 80 60 20 40 10 20 3.4 3.3 0 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 0 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Epidemiological weeks Epidemiological weeks Female Male Figure 2. . Cuba. COVID-19 cases in children and Figure 4. Cuba. Cumulative cases of COVID-19 by sex and adolescents by date of confirmation (percentage of cases epidemiological weeks. aged 0-18 years of total cases in the country). Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. tion of the population and the proportion of cases in In terms of weeks of the evolution of COVID-19 in each group shows the lowest incidence in the 0-5 age the country, there are no differences by sex up to group, a similar amount in the 6-11 age group, and hi- week 15. From this week onwards, the number of gher in the 12-18 age group. However, the percenta- confirmed males rises slightly, maintaining similar ge representation in total cases in the 0-18 age group values in subsequent weeks, with the exception of varies widely from 15 % to just over 70 % of the total week 27, in which 75 % of those confirmed were in week 23; no cases were confirmed in this group in male (Figure 3). week 25 (Figure 5). In epidemiological week 15 (5-11 April), the maxi- Cases 30 mum number of confirmed cases is reached in the 12- 18 and 6-11 age groups, as the 0-5 age group reaches 25 it in week 16. Until week 15, a similar behaviour is 20 observed by age groups. In the following weeks the distribution is irregular (Figure 5). 15

10 Cases 30 5 25 0 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 20 Epidemiological weeks Female Male 15 Figure 3. Cuba. Distribution of COVID-19 cases by sex and epidemiological weeks. 10 Source:Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. 5

The cumulative cases per epidemiological week show 0 that, in general, the number of male cases exceeds the 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 number of female cases (Figure 4). Epidemiological weeks The distribution of children and adolescents diag- 0 a 5 years 6 a 11 years 12 a 18 years nosed with COVID-19 by age group shows the highest Figure 5. Cuba. Distribution of COVID-19 cases by age number of cases in the 12-18 age group in most epide- groups (cumulative cases per week). Source: Ministry of Health’s daily briefings. Department of miological weeks. A comparison between the propor- Health Surveillance’s Database.

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As the epidemic develops, the cumulative cases per is recorded in the 12-18 age group in weeks 15 and 17, day by sex and age show a slight predominance of ma- and male infections in weeks 17 and 27. In the 6-11 age les and the increase of the cases in the 12-18 age range, group, the highest numbers of cases are confirmed for respectively (Figures 6 and 7). females in week 16 and males in weeks 15 and 23. In terms of sex and age, the distribution of cases is Incidence rates increase with age, reaching about irregular (Figure 8). The highest numbers are both ma- 15 per 100 000 in the 12-18 age group (Figure 9). The les and females. A higher number of female infections rates by sex are similar; 11.78 per 100 000 for females

Cumulative Cumulative cases cases 300 300

200 200

100 100

0 0 Date Date 21/03/2 0 02/04/2 0 10/04/2 0 19/04/2 0 29/04/2 0 11/05/2 0 23/05/2 0 04/06/2 0 22/06/2 0 03/07/2 0 21/07/2 0 21/03/2 0 02/04/2 0 10/04/2 0 19/04/2 0 29/04/2 0 11/05/2 0 23/05/2 0 04/06/2 0 22/06/2 0 03/07/2 0 21/07/2 0

Female Male 0-5 years old 6-11 years old 12-18 years old Figure 6. Cumulative cases of COVID-19 in children and Figure 7. Cumulative cases of COVID-19 in children and adolescents (by sex). adolescents (by age group). Source: Ministry of Health’s daily briefings. Department of Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. Health Surveillance’s Database.

Cases 20

15

10

5

0 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Epidemiological weeks Females 0-5 years old Females 6-11 years old Females 12-18 years old Males 0-5 years old Males 6-11 years old Males 12-18 years old Figure 8. Cases of COVID-19 in children and adolescents by sex, age groups and epidemiological weeks. Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database.

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and 12.34 per 100 000 for males. These characteristics The incidence shows a remarkable interprovincial remain in an integrated analysis by sex and age group heterogeneity (Figures 11 and 12). The highest inciden- (Figure 10). ce rates in the period were registered in the provinces of La Habana, Villa Clara and Ciego de Ávila, and the Rate per 100 000 lowest incidence was reported in the eastern provin- 16 ces, particularly in , and Guantána- 14 mo. From week 17 on, Havana exceeds the cases in the 12 other provinces (14), except for weeks 20 and 30 asso- 10 ciated with two epidemic outbreaks in other provinces 8 6 of the country. 4 Rate 2 Cases per 100 000 0 0-5 6-11 12-18 140 35 years old years old years old 120 30 Figure 9. Tasas de indicencia por 100 000 en población de 100 25 0 a 18 años (por grupos de edades). Sourse: Ministry of Health’s daily briefings. Department of 80 20 Health Surveillance’s Database. 60 15

Rate 40 10 per 100 000 20 5 16 14.42 14.53 0 0 14 12.30 12.90 il a 12 una s Holguí n Granm a illa Clara as T 10 9.09 Artemis a L V Camagüey 7.99 La Haban a Mayabequ e Pinar del Rí o

8 Guantánamo Ciego de Áv 6 Sancti Spíritus 4 Provinces 2 0 Total cases Rate per 100 000 inhab. 0-5 6-11 12-18 years old years old years old Figure 11. Incidence of COVID-19 in children and Female Male adolescents (by province). Sourse: Ministry of Health’s daily briefings. Department of Figure 10. Tasas de indicencia por 100 000 en población de Health Surveillance’s Database. 0 a 18 años (por sexo y edad). Sourse: Ministry of Health’s daily briefings. Department of Cases Health Surveillance’s Database. 60 1.2 Provincial distribution of children and adolescents (aged 40 0-18 years) confirmed with COVID-19 The spread of COVID-19 to provinces across the coun- 20 try developed more slowly in children and adolescents than in the adult population. The first case in the age 0 group studied was recorded in in 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 week 12. Two provinces reported their first case in Epidemiological week week 13, eight in week 14, central eastern Camagüey Cuba Havana Other provinces and eastern Holguín in week 15. The last ones to con- Figure 12. Incidence of COVID-19 in children and firm their first case were eastern Guantanamo and Las adolescents (comparison of cases in Havana and other Tunas on 16 April, in week 16. The latter had only one provinces by epidemiological week). Sourse: Ministry of Health’s daily briefings. Department of case in the period. Health Surveillance’s Database.

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2.55 The distribution of cases by province shows that just over 50 % of cases were concentrated in two of the 2.06 country’s 15 provinces, Havana (34.53 %) and Villa Cla- ra (16.14 %). The incidence rate by area (Figure 13) shows that in 1.27 most provinces the urban rate is higher. In the western 1.38 1 provinces of Pinar del Río, Mayabeque and in the cen- 0.76 1.03 1.07 tral eastern province of Ciego de Ávila, the incidence 0.50 0.42 rate in rural areas is higher. 0.53 0.14 0.43 0.07 0.09 0.32 Rate per 100 000 il a 45 na s Tu CUBA Holguín 40 Granma Artemis a Matanza s Las Villa Clara Camagüey La Haban a

35 Cienfuegos Mayabeque Pinar del Rí o Guantánamo Ciego de Áv 30 Sancti Spíritus

25 Santiago de Cuba Provinces 20 15 Advantage Balance Disadvantage 10 Figure 14. Territorial distribution index of cases per 5 province. Fuente: Sourse: Ministry of Health’s daily briefings. Department 0 of Health Surveillance’s Database. vil a una s Holguín Granm a illa Clara as T

Artemis a The number of municipalities involved in the epidemic Matanzas L V Camagüey La Haban a Cienfuegos Mayabequ e Pinar del Rí o

Guantánamo shows wide variations (Figures 15 and 16). The provin- Ciego de Á Sancti Spíritus ces of La Habana (100 %), Villa Clara (61.5 %) and Ciego Provinces Santiago de Cuba de Avila (50 %) have registered confirmed cases in half Urban rate Rural rate or more of their municipalities. On the other hand, Figure 13. Cumulative incidence rate by area. eastern provinces like Santiago de Cuba, Granma, Las Sourse: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. Tunas and Guantanamo have registered cases in less than a quarter of the municipalities with only 1 %, as According to the territorial distribution index of ca- well as the central province of Camagüey. ses per province (Figure 14), which considers Cuba=1, Percentage in the provinces of La Habana and Villa Clara, with of the total an index higher than 2, the magnitude of the spread 100 of cases double the one from the rest of the country. 80 The provinces of Mayabeque and Ciego de Ávila are at 65 a slight disadvantage. The rest of the provinces are in 40 an advantageous situation and Las Tunas reaches the 20 minimum index value. The provinces of Pinar del Río 0 e and Sancti Spítitus with values closer to 1, are conside- o vil a red to be in balance with the spread of COVID-19 in the una s Holguí n Granma illa Clara as T Matanzas L V Camagüey country. La Haban a Cienfuegos Mayabequ Pinar del Rí Guantánamo Ciego de Á In week 17, 95.21 % of the municipalities had confir- Sancti Spíritus med cases among children and adolescents. The muni- Provinces Santiago de Cuba cipality of in reported Figure 15. Number of municipalities with confirmed cases for the first time in week 21 as Bauta in Artemi- cases by epidemiological week (percentage of the total sa province became the last municipality to confirm a municipalities with notifications). Sourse: Ministry of Health’s daily briefings. Department of case in the period under study in week 22. Health Surveillance’s Database.

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Cases 25 reports the lowest amount of cases. The municipality 20 of Regla has not reported cases since week 18. 15 10 1.3 Municipal distribution of 5 children and adolescents (aged 0-18 0 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 years) confirmed with COVID-19. Epidemiological weeks The incidence of COVID-19 by municipality shows Total of municipalities conrming cases a high degree of heterogeneity. Forty municipalities, Total of municipalities conrming cases for the rst time 63.5% of the country’s total, have reported fewer than Figure 16. Cantidad de municipios con casos por semana five cases, as 19 of them have only confirmed one case. epidemiológica (totales y primeras notificaciones). Twelve municipalities have recorded between 5 and Sourse: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. 8 cases, as eleven municipalities have registered 10 or more cases. This group includes the majority of the The province of Havana shows differences in how municipalities in Havana (70 % of the total), which in- the disease spreads at the municipal level in relation clude the homonymous provincial capitals of Pinar del to the country. In week 14, 16 days after the first case Río, Matanzas, Camagüey and Santiago de Cuba, as was reported in the country, a nine-year-old girl, a re- well as San José de las Lajas in , sident in the Cerro municipality, was confirmed with and Santa Clara in Villa Clara Province (Table 1). the disease. During weeks 14 and 15, cases were recor- Incidence rates range from 16.66 to less than 1 per ded in seven of the 15 municipalities in Havana, 11% 10,000 (Table 2). Fourteen municipalities have both a of the total with confirmations in the period under relatively high number of infected children and ado- study, when 87 % of the municipalities involved in the lescents, and high incidence rates, including Taguasco country had already reported cases. In week 16, four and in the central region, and Cen- municipalities joined and by the end of week 17, infec- tro Habana in Havana Province, to the west (Figures tions were recorded in children and adolescents in all 17 and 18, Maps 1 and 2). municipalities. In 28 (45 % of the total) of the country’s municipalities Up to week 30, the municipalities with the highest with cases in the age group studied, the incidence of CO- number of children and adolescents infected in Hava- VID-19 is one or less per 10,000 children and adolescents. na were Centro Habana, San Miguel del Padrón, Cerro Four have remained with the highest figures, all with and Cotorro, the latter reporting 61.54 % of total cases epidemic outbreaks of higher number of cases, in the cen- in week 27. The Plaza de la Revolución municipality tral part of the country ( Figures 17 and 18, Map 2).

Cuadro 1. Municipalities with the highest number of cases. Cuadro 2. Municipalities with the highest incidence rates. MUNICIPALITIES CASES MUNICIPALITIES RATE PER 10 000 Santa Clara 14 Taguasco 16.66 Centro Habana 13 Florencia 12.10 San Miguel 13 Venezuela 10.05 Cotorro 13 9.55 Cerro 12 Cotorro 7.46 12 Centro Habana 5.67 Taguasco 11 Regla 5.65 10 5.57 La Lisa 10 San Jose de las Lajas 5.52 San José de las Lajas 10 Cerro 5.35 Camajuaní 10 Bauta 4.63 Sourse: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. Index of Human Settlements. CEPDE-ONEI 2017.

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Cases 16 S. Miguel del Padrón Santa Clara 14 Centro Habana Cotorro 12 Taguasco Camajuaní 10 8 Venezuela 6 Florencia 4 Limonar 2 0 Municipalities WEST EAST Figure 17. COVID-19 incidence rate differences across municipalities (cases). Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database.

Rate per 100 000 18 Taguasco 16 14 Florencia 12 Venezuela 10 Camajuaní 8 Cotorro 6 Limonar 4 2 0 Municipalities WEST EAST Figure 18. COVID-19 incidence rate differences across municipalities (rate per 10 000 children and adolescents). Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database.

Map 1. Cuba. COVID-19 cases by municipalities in population aged 0-18 years. Week 12-30 (21 March to July 25).

NORT

04 8 kilómetros

Cases 10 to 14 5 to 9 2 to 4 1 No cases 075 100 kilómetros

Source: Ministry of Health’s daily brie ngs. http://salud.msp.gob.cu/ Digital cartographic database 1:1000 000 Geo Cuba Author: Luisa Iñiguez Rojas, FLACSO, University of Havana Ángel Miguel Germán Almeida. IPK. MINSAP Laura Almora Andarcio. CIPS, CITMA.

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Mapa 2. Cuba. Incidence of COVID-19 cases by municipalities in population aged 0-18 years. Week 12-30 (21 March to July 25).

NORT

04 8 kilómetros

Rate per 10 000 inhabitants (aged 0-18 years) 10.05 to 16.67 3.21 to 5.58 1.02 to 2.95 0.19 to 0.97 No cases 075 100 kilómetros

Fuente: Ministry of Health’s daily brie ngs. http://salud.msp.gob.cu/ Digital cartographic database 1:1000 000 Geo Cuba Author: Luisa Iñiguez Rojas, FLACSO, University of Havana Ángel Miguel Germán Almeida. IPK. MINSAP Laura Almora Andarcio. CIPS, CITMA.

Transmission in rural areas is one of the charac- 1.4. Distribution of children teristics of the spread of the epidemic in the country, and adolescents (aged 0-18 years) which is also a distinctive feature of the behaviour of confirmed with COVID-19 by the disease in children and adolescents. Rural rates human settlements. are higher than urban rates in some municipalities Infected children and adolescents have been repor- (Figure 19): in Guane and Consolación del Sur in the ted in all types of human settlements in the country western end of the island, in Mayabeque’s head mu- (Figure 20). Just over 73.3 % of the total number of nicipality San José de las Lajas, and in Florencia in cases have been confirmed in cities. Just over 40 per- the province of Ciego de Ávila. cent are concentrated in the country’s capital, where

Rate per 100 000 25 Taguasco Florencia 20

San José de las Lajas Camajuaní 15 Venezuela

Guane Ranchuelo 10

5

0 Municipalities WEST EAST Urban rate Rural rate Figure 19. Municipal differences in COVID-19 incidence rate in children and adolescents by area. Each bar represents a municipality with cases. Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database.

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Cases Percentage The distribution of cases in all categories of human 140 50 settlements shows, as discussed above, the highest 120 number in the country’s capital. Settlements regarded 40 as provincial and municipal capitals report similar 100 numbers of confirmed cases. A lower incidence is ob- 80 30 served in other urban settlements. About 12 % of the total was detected in rural settlements and in scattered 60 20 housing (Table 3). 40 Table 3. Distribution of cases by category of settlement. 10 CATEGORY OF NO. OF 20 CASES % SETTLEMENT SETTLEMENT 0 0 Country´s capital 1 125 44.96 ABCDEF Provincial capitals 9 47 16.91 Cases Percentage Municipal capitals 22 48 17.27 A: Capital city, B: Others cities Other urban settlements 15 24 8.63 C: Towns, D: Urban Settlements, E: Rural Settlements, Rural settlements and F: Hamlets and scattered housing 19 34 12.23 scattered housing Figura 20. Distribución de casos por tipos de asentamientos. Source: Ministry of Health’s daily briefings. Department of Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. Index of Human Settlements. Health Surveillance’s Database. Index of Human Settlements. CEPDE-ONEI 2017. CEPDE-ONEI 2017. La distribución por semanas de casos muestra que 17 percent of the total population aged 0-18 years live, a partir de la semana 17, la detección en la capital su- showing their disadvantage in the spatial evolution peró al resto de los asentamientos de otras categorías. of the epidemic. Urban villages follow cities with the La excepción está en la semana 21, en que los casos en highest frequency of cases in absolute and relative sedes municipales son superiores. El mayor número de numbers. Rural villages, hamlets and scattered hou- contagios en sedes provinciales, municipales y otros sing account for about 12 % of the total number of re- asentamientos urbanos ocurrió en la semana 15, y en ported cases. la capital en la semana 18 (Figura 21).

Cases 25

20

15

10

5

0 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Epidemiological weeks Country´s capital Settlements and scattered population Municipal capitals Other urban settlements Provincial capitals Figure 21. Distribution of cases by category of settlement. Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. Index of Human Settlements. CEPDE-ONEI 2017.

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The number of children and adolescents infected for about 18 % of the total number of people infected, with the virus generally falls as the population size of similar to the number of people infected in settlements the settlements decreases. However, the smallest sett- with 100,000-500,000 inhabitants (Figure 22). lements with fewer than 5,000 inhabitants, account When looking more closely at the location of cases by place of residence through the Index of Human Se- Cases Percentage ttlements, it is found that in 66 of the 7014 settlements 140 50 2 45.0 % in the country, cases in population aged 0-18 years 120 have been confirmed. This figure exceeds the one from 40 the first report, which recorded 59. Likewise, the num- 100 ber in rural settlements has increased from 16 to 19, in urban settlements from 43 to 47 and one case remains 30 80 in scattered population. Havana, regarded as one single settlement by the 60 18.0 % 20 Index of Human Settlements, accumulates 125 ca- 16.9 % ses distributed in its 15 municipalities. For the period 40 11.1 % under analysis, the total number of cases confirmed 9.0 % 10 increased from 34.53 to 45 %, with a clear concentra- 20 tion in neighbourhoods in the municipalities of Centro 0 0 Habana, Cerro, San Miguel del Padrón and Arroyo Na- More than From 100 000 From 20 000 From 5 000 Less than ranjo (Maps 3 and 4).3 500 000 to 500 000 to 100 000 to 20 000 5 000

Cases Percentage Figure 22. Cases according to population size of 2 Index of Human Settlements. Population and Housing Census settlements. 2012, CEPDE-ONEI 2017. Source: Created by the authors based on information from 3 Havana is shown separately from the map of Cuba because of MINSAP, 2020 and ONEI, 2017. cartographic scale of presentation reasons.

Mapa 3. Cuba. Location of COVID-19 confirmed children and adolescents by settlements. Epidemiological weeks 12-30 (21 March to 25 July).

Havana: 125 cases

NORT

Urban cases Rural cases 14 5 7 3 1 1

Settlements

075 100

Fuente: Department of Health Surveillance’s Database, MINSAP kilómetros Index of Human Settlements, ONEI, 2017. ONEI 2017. Digital cartographic database 1:1000 000 Geo Cuba Author: Luisa Iñiguez Rojas, FLACSO, University of Havana Edgar Figueroa Fernández. CEPDE-ONEI 2017.

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Mapa 4. Havana. Location of COVID-19 confirmed children and adolescents. Epidemiological weeks 14-30 (21 March to 25 July).

NORT

PCR confirmed*

6 321 2.5 0 2.5 5 kilómetros Neighbourhood limits Health area limit Municipal limit Reservoirs Fuente: Parte del MINSAP. Base: 1:2000 GeoCuba. Autores: Dra. Luisa Iñiguez Rojas. * Five children were not located because the address of the place where they got infected is not available Redacción cartográ ca: Lic. Laura E. Almera Andarcio, (the health areas where the transmission occurred are known). M.Cs. Antonio Herrada Hidalgo

1.5. Spatial clusters and The results (Figure 23) show that approximately 25 % transmission sources of the children and adolescents were infected by A cluster is defined by the presence, in the same geo- the mother, father or both. Few infections occurred graphical area and/or with epidemiological linkage, of from other cohabiting relatives, predominantly from two or more people with manifestations of acute respi- Sources of transmission ratory infection (ARI), detected within a period of time Mothers, fathers from the onset of symptoms (Pan American Health or both conrmed 24.58 Organization, 2002). or asymptomatic A first approach to spatial aggregates of Cuban Other conrmed children and adolescents confirmed with COVID-19, cohabiting relatives 8.37 with the purpose of understanding the ways of trans- mission in these age groups, consisted in linking the Non-cohabiting location of cases in human settlements, with the epi- relatives 15.64 demiological observations contained in the available databases on the sources of transmission. Third parties 46.92 The analysis covered 65 % of the total confirmed cases up to epidemiological week 30, and allowed to determine the following sources of infection: Other countries (imported cases) 4.47 ɐɐ Mothers, fathers or both confirmed or asympto- % matic. 0 10 20 30 40 50 ɐ Other confirmed cohabiting relatives. ɐ Figure 23. Sources of transmission in Cuban children ɐɐ Non-cohabiting relatives. and adolescents confirmed with COVID-19up until ɐɐ Third parties. epidemiological week 30. Source: Created by the authors based on data from MINSAP, ɐɐ Other countries (imported cases). Department of Health Surveillance’s Database 2020.

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siblings, grandparents and even great-grandparents. cohabitant relatives, especially mothers, fathers This way, 33 % of the transmission processes occurred or both. among relatives within the home. If we add infection ɐɐ Cluster in towns and villages, related to social from other non-cohabiting relatives, especially aunts interactions between peers in the 12-18 age group, and cousins, this transmission reaches 49 % of the total and in particular 16-18 year olds. analysed, without information about the specific place ɐɐ Cluster in villages and hamlets, involving related of the transmission. and visiting people who start a transmission pro- On the other hand, a high number of children and cess to children and adolescents. adolescents (47 % of the total) were infected by other adults, young people and even adolescents. Transmis- In general, spatial clusters are more frequently associa- sion from neighbouring adults, visitors to the place of ted with some of the outbreaks that have accumulated residence, and even children who visited places where the greatest number of infected people in settlements, confirmed cases had been recorded, seem to happen city districts, villages and even hamlets of several na- more frequently. tures. These outbreaks include pendulum movements The analysis that integrates the sources of trans- of relatives and neighbours, or visits or arrivals of cases mission with the location of cases in settlements and from abroad (imported cases). In this regard, it should neighbourhoods of the city, set out in the previous be noted that, as of 24 March, according to the coun- sections, allows us to identify types of spatial clusters. try’s epidemiological surveillance protocol, people arri- This way, the study moved from where to how the pro- ving from abroad are taken directly to isolation centres cesses of transmission of the virus in children and ado- or health institutions. lescents take place. Some of the spatial clusters relate to neighbouring At the time of concluding this second report, the settlements, even from different provinces. These are four most frequent types of spatial clusters have been formed as a result of networks of social interactions, identified: especially kinship. Relatively often, clusters are found ɐɐ Cluster in cities, associated with neighbourhood or in the same housing building. institutional outbreaks with transmission of the The figures below represent types of spatial clusters virus to the child and adolescent population. of cases of children and adolescents. Infections occu- ɐɐ Small cluster distributed in all types of sett- rring in the population over 18 years of age are exclu- lements, whose sources of transmission are ded (Figures 24, 25 and 26).

INDEX CASE INDEX CASE

MEN (43 years old) WOMEN (43 years old) WOMEN (43 years old)

SON SON NEIGHBOUR NEIGHBOUR DAUGHTER NEIGHBOUR NEIGHBOUR (9 years old) (13 years old) (13 years old) (15 years old) (17 years old) (14 years old) (18 years old)

NEIGHBOUR (9 years old) NEIGHBOUR (17 years old)

LEGEND: Cases infected in the same neighbourhood Residents in an area different Con rmed non-cohabitant relatives or settlement of the outbreak from the place of infection

Figure 24. Cluster in rural settlements and neighbourhood buildings in cities with source of transmission from father, mother or both confirmed, children or grandchildren, neighbouring children and adolescents. Source: Created by the authors after processing the MINSAP´s daily briefings, Department of Health Surveillance’s Database, MINSAP, 2020.

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INDEX CASE

WOMAN (43 years old)

SON (20 years old)

GIRLFRIEND (17 years old)

NEIGHBOUR (16 years old)

BROTHER NEIGHBOUR NEIGHBOUR NEIGHBOUR (6 years old) (16 years old) (16 years old) (16 years old)

NEIGHBOUR NEIGHBOUR NEIGHBOUR (17 years old) (17 years old) (17 years old)

LEGEND: Cases infected in the same neighbourhood or settlement of the outbreak NEIGHBOUR (16 years old) Figure 25. Cluster with source of transmission in an adult living in a settlement different from where the outbreak takes place, involving mostly infected adolescents. They are supposedly students from the same school, which is now inactive. Source: Created by the authors after processing the MINSAP´s daily briefings, Department of Health Surveillance’s Database, MINSAP, 2020.

INDEX CASE

WOMAN (64 years old)

GRANDSON (9 years old)

NEIGHBOUR (16 years old)

BROTHER NEIGHBOUR NEIGHBOUR NEIGHBOUR NEIGHBOUR (18 years old) (7 years old) (16 years old) (16 years old) (4 years old)

LEGEND: Cases infected in the same neighbourhood or settlement of the outbreak BROTHER (17 years old)

Figura 26. Cluster with source of transmission in a cohabitant relative who infects children and adolescents in the neighbourhood. Source: Created by the authors after processing the MINSAP´s daily briefings, Department of Health Surveillance’s Database, MINSAP, 2020.

-15- General conclusions It is observed that incidence rates of COVID-19 in Cu- the concentration of cases in cities and the country’s ban children and adolescents remain without signifi- capital, and the second is the concentration of cases cant differences in terms of sex, up until 25 July, the in rural villages and hamlets. Remarkably, in several last day of epidemiological week 30, and eight weeks municipalities, cases are not located in the municipal after the first report. By age group, the rates remain hi- capitals, but in small towns relatively distant from gher in the 12-18 age group, with a slight increase. The these ones. This finding reveals the role of social re- urban rate is still twice as high as the rural rate. Howe- lation networks in transmission, regardless of the size ver, the number in small human settlements (5,000 in- of the settlements or the density of the population. It habitants and less) is increasing, as well as the number also serves as a warning, once again, about the con- of children and adolescents infected in rural villages sequences of neglecting protective measures, trans- and hamlets. gressions in which parents, other relatives and even Findings show the epidemic is concentrating in spe- neighbours, as well as adolescents themselves, are cific provinces so by the end of week 30, only the wes- involved. tern provinces of Artemisa, Mayabeque and Havana The analysis of the routes of transmission to chil- were reporting cases. The three provinces had a nota- dren and adolescents shows a similar relative frequen- ble concentration of 45% of the total cases of the period cy with which they get infected from both cohabitant (week 12 to 30) in the age group studied. relatives and from people they have maintained regu- The number of municipalities that had reported a lar or circumstantial social interactions with, both in- child or adolescent with COVID-19 did not vary, and side and outside the home. they represent nearly 40 % of the total number of mu- The third report, currently under preparation, will nicipalities in the country. No relationship was found update and analyse in more detail the results obtained, between the number of population in the municipali- especially regarding sources of transmission, and will ties and the number of cases among children and ado- include an analysis of the identified epidemiological lescents. The absence of cases in municipalities where phases. four of the 14 provincial capitals are located, with lar- ger populations and where more intense social interac- 1 September 2020 tions are supposed to occur, shows that this indicator is Second task report of project “COVID-19 in children not always a determinant of spatial distribution. and adolescents in Cuba”. The location by human settlement shows two pa- Health and Social Sciences Topics. FLACSO-Cuba. tterns of spatial propagation of COVID-19. The first is University of Havana

-16- References Ballarini, F., Arriola, L., Santagapita, P., & Bonnin, J. Oficina Nacional de Estadísticas e Información (ONEI). (28 de Agosto de 2020): Coronavirus en la infancia: (2017): Nomenclador de Asentamientos Humanos. preguntas frecuentes y algunos mitos que es mejor de- Censo de Población y Viviendas 2012. La Habana: rribar. Obtenido de Chequeado: https://chequeado. ONEI. com/el-explicador/coronavirus-en-la-infancia-pre- Oficina Nacional de Estadísticas e Información guntas-frecuentes-y-algunos-mitos-que-es-me- (ONEI). (2020): Anuario demográfico de Cuba 2019. jor-derribar/ La Habana: ONEI. CDC. (8 de sept de 2020): Coronavirus Disease 2019 (CO- Oficina Nacional de Estadísticas e Información (ONEI). VID-19). Obtenido de Centers for Disease Control (2020): Indicadores demográficos de Cuba y sus terri- and Preention: https://www.cdc.gov/coronavi- torios. La Habana: ONEI. rus/2019-ncov/hcp/pediatric-hcp.html Organización Panamericana de la Salud. (2002): Íñiguez Rojas, L., Figueroa Fernández, E., Germán Almei- Módulos de Principios de Epidemiología para el da, A., Álvarez, M., Somarriba, L., Herrada Hidalgo, control de enfermedades (segunda edición ed.). A., & Almora Andarcio, L. (2020): Características Washington D.C: OPS. Obtenido de https://www. epidemiológicas y espacialidad de la COVID-19 en ni- paho.org/bra/index.php?option=com_docman&- ños y adolescentes. Junio 2020. La Habana: UNICEF view=download&alias=1273-modulos-princi- Cuba. Obtenido de https://www.unicef.org/cuba/ pios-epidemiologia-para-control-enfermeda- informes/caracteristicas-epidemiologicas-y-espa- des-mopece-unidad-5-investigacion-epidemiolo- cialidad-de-la-covid-19-en-ninos-y-adolescentes gica-campo-aplicacion-al-estudio-brotes-3&cate- LunaA-Bazaldua, D., & Pushparatnam, A. (9 de agosto gory_slug=informacao-e-analise-s de 2020): Banco Mundial Blogs. Obtenido de UNICEF. (agosto de 2020): Obtenido de UNICEF Data: Banco Mundial: https://blogs.worldbank.org/es/ Monitoring the situation on children and women: education/la-importancia-de-monitorear-los-im- https://data.unicef.org/resources/resource-topic/ pactos-de-la-pandemia-covid-19-en-infan- covid-19/ tes-y-sus?cid=ECR_E_NewsletterWeekly_ES_EX- T&deliveryName=DM77071

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