COVID-19 in Cuban Children and Adolescents. Third Report. Epidemiological Weeks 31-40, October 2020

COVID-19 in Cuban children and adolescents. Third report. Epidemiological weeks 31-40, October 2020.

Luisa Iñiguez Rojas. FLACSO-Cuba. University of Havana.

Edgar Figueroa Fernández. CEPDE-ONEI.

Laura Almora Andarcio. CIPS. CITMA.

Angel Miguel Germán Almeida. IPK.Minsap.

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

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

1.1. Evolution of the general characteristics of COVID-19 in children and adolescents from week 12 to 40 | 04

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 | 12

1.5. Sources of transmission in children and adolescents | 15

Final considerations | 18

References | 19 After the epidemic reached a peak between weeks on the situation between weeks 31 and 40, and the 15 and 18, there was a decrease in the number of CO- comparison between both epidemic waves, while the VID-19 cases in the country, as they concentrated in a second one is still in progress. few municipalities, mostly from Havana and two from As seen in the two previous reports (June and July the neighboring province of Artemisa. This behavior 2020), this is a descriptive cross-cutting study that ex- is also reflected in the number of children and adoles- poses the characteristics of the spread of the epidemic cents infected with the coronavirus. according to individual specifications of sex and age of From week 301 onwards, the number of cases in- children and adolescents infected, and analyzes the creased, and up until week 40, the last week analyzed spatial spread according to political-administrative di- in this report, the country faced what could be con- vision levels of the country, variables of the Human sidered a second epidemic wave. Regardless of diffe- Settlement System, and especially the location of cases rent opinions about the actual occurrence of a second by residence or most likely place of infection. In the wave, which had been announced since April, the study period, no deaths have been reported in chil- event has been described in several countries, given dren and adolescents and up to week 40, about 90% the increase in the number of cases following their of confirmed patients have already been clinically dis- sustained decline. The second wave is usually associa- charged with strict follow-up by their health areas2. ted to the restart of daily activities, the reduction or The fundamental sources of the study come from elimination of containment measures and the conse- the database of the Ministry of Health’s Surveillance quent decrease in perception of risk or danger of con- Center, other databases on population and settlements tagion (Lockerd Maragakis, 2020) (Shunqing & Yuan- of the National Office of Statistics and Information yuan, 2020) (Horton, 2020). (ONEI), as well as mapping resources from GeoCuba This report provides an update on the behavior of Business Group. It is possible that some of the infor- COVID-19 in Cuban children and adolescents in 40 mation used may have been updated after the date of weeks of its evolution in the country, with emphasis this report, which could cause variations in some of the absolute numbers exposed. The relative frequen- 1 Hereafter, this report will use the term week and the corres- cies are unlikely to vary. ponding numbers to refer to the epidemiological weeks; time period which groups epidemiological events for surveillance actions and the analysis of the behaviour of diseases, especia- 2 The health area consists of a polyclinic and a number of family lly communicable ones. The epidemiological calendar is the in- doctor and nurse’s offices, according to the amount of the po- ternational standardization instrument for the time variable. pulation who receive attention.

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Percentage of cases 1.1 Evolution of the general 0-18 years old characteristics of COVID-19 in 50 children and adolescents from 40 week 12 to 40 30 From week 30 onwards, there has been an increase in confirmed cases of COVID-19 in children and adoles- 20 cents, which has been regarded as a second epidemic 10 wave and officially described as a fresh outbreak of the 0 11 13 15 17 19 21 23 25 27 29 31 33 35 37 40 disease in the country (Figure 1). Epidemiological weeks Cases Figure 2. Cases detected in children and adolescents from 70 the total number of confirmed cases in the country per epidemiological week. 60 Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. 50 40 nance of one of them, with more noticeable differences 30 in favor of females in weeks 31 and 36. Thus, female 20 cases have increased from 50.74% to 53.5% between 10 the first and second epidemic wave, and its increase is 0 11 14 16 18 20 22 24 26 28 30 32 34 36 38 40 especially observed in weeks 33 and 36. The inciden- Epidemiological weeks ce rate between weeks 12 and 40 reached 29.05 per Figure 1. Cuba. COVID-19 in children and adolescents, 100,000 girls and female adolescents and 26.54 in boys weeks 12 to 40. and male adolescents, according to the rising waves in Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. both sexes, with more noticeable differences among females (Figures 3 and 4). Compared to the first epidemic wave, which lasted Cases 18 weeks, the second wave, with 10 weeks of evolu- 35 tion, accumulates 56% of the total number of cases, 30 showing greater intensity. The incidence rate be- 25 20 tween weeks 12 and 30 was 12.11 and rises from 31 15 to 40 to 15.64 per 100,000 children and adolescents. 10 The cumulative rate reaches 27.75 per 100,000 people 5 0 aged 0 to 18 years old. 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 The detection of cases in children and adoles- Epidemiological weeks cents registered in 40 weeks of evolution represents Female Male approximately 11%3 of the total. The figure drops to less Figure 3. Cases of COVID-19 in children and adolescents than 5% of the total in some weeks, while in week 27, by sex and epidemiological weeks. Source: Ministry of Health’s daily briefings. Department of it exceeds 40%. More than half of the 17 detected cases Health Surveillance’s Database. occurred in only one municipality of the province of Sex Havana (Figure 2). The differences by sex are not significant in the pe- Female riod under study, with 50.7% of females and 49.7% of Male males. In terms of epidemiological weeks, the number of cases by sex approaches or shows a slight pre-domi- 0 5 10 15 20 Tasa por 100 000 First Wave Second Wave 3 This is calculated by using a total of cases, without the imported cases from the moment when all people arriving in the Figure 4. Incidence rates by sex and epidemic waves. country were isolated in centres created for that purpose or Source: Ministry of Health’s daily briefings. Department of health centres. Health Surveillance’s Database.

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Cases By age group, the highest number of cases detected 30 in the 12 - 18 age group in the first wave remains with 42.86% of the total cases. In the second wave, there is 25 a slight decrease in those confirmed in the 6 - 11 and 20 12 – 18 age groups, and an increase in those aged 0 to 5 15 years (Figure 5). 10 Percentage of the total 5 50 0 40 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 30 Epidemiological weeks 20 10 0-5 years old 6-11 years old 12-18 years old 0 Figure 7. Distribution of cases by age groups and First wave Second wave epidemiological weeks. 0-5 years old 6-11 years old 12-18 years old Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. Figure 5. Cases by age groups in percentage of the total. Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. By age group, 61% of cases in the 12-18 age group are female and 55% of cases in the 6-11 age group are In accordance with the increase in transmission male. In the 0 to 5 age group the figures are similar among children and adolescents in the last weeks, for both sexes. Incidence rates by sex remain similar and considering a steady age structure, the incidence throughout the period, although it is observed that rate in all age groups rises and their values come clo- from close values in the first epidemic wave, there is ser, with the exception of the 0-5 age group that goes an increase in female cases in the 12-18 age group du- from approximately 9 to 15 per 100,000 people be- ring the second wave, without significant changes in tween those ages. The highest rate of the entire study the other groups. (Figures 8 and 9). period corresponds to the 12-18 age group with 31.87 Rate per 100,000 adolescents in this group. It drops to 27.11 by 100 000 per 100,000 in the 6 -11 age group and to 23.39 per 16 100,000 in the 0 - 5 age group. (Figure 6). 12 8 Rate 4 by 100 000 0 50 0-5 years old 6-11 years old 12-18 years old 40 Female Male 30 Figure 8. Distribution of cases by sex and age. 20 Weeks 12-30. 10 Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. 0 De 0 a 5 años De 6 a 11 años De 12 a 18 años Rate Primera onda Segunda onda by 100 000 Figure 6. Incidence rates per 100,000 children and 25 adolescents by age groups. 20 Source: Ministry of Health’s daily briefings. Department of 15 Health Surveillance’s Database. 10 5 0 The increase in cases among the 12-18 age group is sig- 0-5 years old 6-11 years old 12-18 years old nificant in several weeks, a situation that is reinforced Female Male as of week 33, with the exception of week 39, when a Figure 9. Distribution of cases by sex and age. greater number of cases were confirmed in the 6-11 age Weeks 31 to 40. Source: Ministry of Health’s daily briefings. Department of group (Figure 7). Health Surveillance’s Database.

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Cases Later studies may explain the increase in girls and 50 adolescents during the second wave of the epidemic 40 of the country. The cumulative cases show the similarity of the dis- 30 tribution by sex and the increase of the 12-18 age group 20 in the last weeks of the study (Figures 10 and 11). 10 0 Cumulative cases 11 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 700 600 Epidemiological weeks 500 La Habana Other provinces 400 300 Figure 12. Casos de COVID-19 en niños y adolescentes. La 200 Habana y las demás provincias. 100 0 Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. Date Provinces 21/03/2 0 12/04/2 0 05/05/2 0 31/05/2 0 03/07/2 0 04/08/2 0 22/08/2 0 09/09/2 0 27/09/2 0 03/10/2 0 Guantánamo Female Male Santiago de Cuba Granma Figure 10. Cumulative cases in children and adolescents Holguín by sex according to epidemiological weeks. Las Tunas Source: Ministry of Health’s daily briefings. Department of Camagüey Health Surveillance’s Database. Ciego de Avila Sancti Spíritus Cumulative cases Cienfuegos 700 Villa Clara 600 Matanzas 500 400 Mayabeque 300 La Habana 200 Artemisa 100 Pinar del Río 0 0 100 200 300 400 Cases Date Figure 13. Casos de COVID-19 en niños y adolescentes por

21/03/2 0 12/04/2 0 05/05/2 0 31/05/2 0 03/07/2 0 04/08/2 0 22/08/2 0 09/09/2 0 27/09/2 0 03/10/2 0 provincias. Source: Ministry of Health’s daily briefings. Department of 0-5 years old 6-11 years old 12-18 years old Health Surveillance’s Database. Figure 11. Casos acumulados en niños y adolescentes por grupos de edades según semanas epidemiológicas. epidemic wave maintains the territorial heterogeneity Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. of the first one, with some distinctions. The province of Havana experiences the greatest increase in notifi- 1.2. Provincial distribution of cations over the last 10 weeks (31 to 40). Havana con- children and adolescents (aged centrated 65% of total cases of children and adolescents 0-18 years) confirmed with in the country, a figure higher than the one reached in COVID-19 the first wave (45% of the total). When comparing both The detection of cases of COVID-19 in children and epidemic waves by province, it is shown that in the se- adolescents showed a high provincial heterogenei- cond wave, 8 out of 15 provinces did not detect cases, ty since the first weeks of evolution. The province of three reported a decrease and five registered an increa- Havana concentrates 56% of the total registered cases se. About 94% of the cases were concentrated in four of children and adolescents in the period under study. provinces that reported epidemic outbreaks of greater The provinces of Ciego de Avila, Villa Clara and Arte- magnitude, with institutional and neighborhood ori- misa have more than 30 total cases (Figures 12 and 13). gin in several settlements in the western provinces of The province of Havana registered about 125 cases Havana and Artemisa, in the eastern center area of the in 19 weeks of evolution. More than 100 new cases province of Ciego de Avila and in the central province were confirmed in the following 10 weeks. The second of Sancti Spíritus

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Havana is still the province with the highest number The detection of cases by type of population in the of cases while the highest rates are registered by Ciego whole period (week 12 to 40) shows that urban settle- de Avila, Artemis and Sancti Spírus (Figures 14 and 15). ments report more cases than rural ones in most of the provinces, with the exception of Pinar del Río and Maya- Provinces Guantánamo beque. Rural cases were recorded in 9 of the 15 provinces Santiago de Cuba and it is striking that those provinces with the highest Granma percentage of children and adolescents in rural areas of Holguín Las Tunas the country, like the provinces of Granma and Guantá- Camagüey namo, did not report any cases. Between the first and Ciego de Avila second epidemic waves, cases decreased in rural areas, Sancti Spíritus Cienfuegos while 3 cases were detected in the province of Sancti Spí- Villa Clara ritus and the number increased in the provinces of Ciego Matanzas de Ávila and Artemisa (Figures 16 and 17) Mayabeque Artemisa Provinces Pinar del Río Guantánamo 0204060 Cases Santiago de Cuba Granma Weeks 31-40Weeks 12-30 Holguín Figure 14. Cases of COVID-19 in children and adolescents Las Tunas by provinces. Total from weeks 12 to 40.. Camagüey Source: Ministry of Health’s daily briefings. Department of Ciego de Avila Health Surveillance’s Database. Sancti Spíritus Cienfuegos Provinces Villa Clara Guantánamo Matanzas Santiago de Cuba Mayabeque Granma La Habana Holguín Artemisa Las Tunas Pinar del Río Camagüey 0102030 40 Cases Ciego de Avila Rural Urban Sancti Spíritus Cienfuegos Figure 16. Cases by province and type of population. Villa Clara Weeks 12 to 30. Matanzas Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. Mayabeque Artemisa Provinces Pinar del Río Rate Guantánamo 0210 0630 40 50 0 70 by 100 000 Santiago de Cuba Granma Weeks 31-40Weeks 12-30 Holguín Figure 15. Cases of COVID-19 in children and adolescents Las Tunas by provinces. According to a comparison between the first Camagüey and the second epidemic wave. Ciego de Avila Sancti Spíritus Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. Cienfuegos Villa Clara Matanzas The eastern province of Granma reported its last case Mayabeque La Habana in week 14. Provinces of Pinar del Río in the west, Cien- Artemisa fuegos in the center and eastern Santiago de Cuba re- Pinar del Río ported their last case in week 17. Holguín and Guantá- 0102030 40 50 Cases namo, in week 18, and the eastern center of Camagüey, Rural Urban in week 20. The five eastern provinces have maintai- Figure 17. Cases by province and type of population. ned the lowest transmission. Only the province de Las Weeks 31 to 40. Source: Ministry of Health’s daily briefings. Department of Tunas detected 3 children in the second wave. Health Surveillance’s Database.

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1.3. Municipal distribution of of the country, the concentration of confirmed cases children and adolescents (aged 0-18 in the municipalities of Havana, as well as the reduc- years) confirmed with COVID-19 tion of municipalities with cases in the last 10 weeks Up to week 40, 90 municipalities (53.57% of the total) of the epidemic’s evolution had no confirmed cases among the population aged 0-18 Number years. In the first epidemic wave, cases were reported in of municipalities 105 municipalities and in the second, in 42. The territo- 25 rial spread of COVID-19 between weeks 12 and 40, in terms of the country’s municipalities, shows that 46.43% 20 (78 municipalities) had confirmed infected children and adolescents. 55.13% had less than 5 confirmed cases, and 15 18 of them had only one. Between 5 and 9 cases were detected in 14 municipalities and 10 or more cases, in 21 of 10 them. Eleven municipalities report more than 20 cases. With regard to the territorial spread of COVID-19 in the 0 general population, its impact on the child and adoles- 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 cent population has been relatively limited. Epidemiological weeks The number of municipalities with cases per epi- Total municipalities Municipalities con rming demiological week is related to the number of cases, con rming cases cases for the rst time so they both increase after week 30. However, be- Figure 18. Municipalities with confirmed cases. Weeks tween weeks 12 and 30, 63 municipalities register 12 to 40. Source: Ministry of Health’s daily briefings. Department of confirmed cases, while they dropped to 42 between Health Surveillance’s Database. weeks 31 and 40, and in 15 of them transmission was detected in children and adolescents for the first Municipalities of Havana and those where epidemic time. Only 27 municipalities report cases in both epi- outbreaks occurred in the western, central and cen- demic waves (Figure 18). tral-eastern parts of the country report more confir- The distribution of confirmed cases by municipa- med cases in the second wave. lity shows the significant territorial heterogeneity of A total of 27 municipalities confirmed cases in the the spread of the virus in children and adolescents, two epidemic waves, these ones are concentrated in with 10 or more cases recorded in 21 municipalities, the provinces of Havana, Ciego de Avila, and some in and only one case in 18 municipalities. It is worth no- the western and central parts with larger epidemic ting the limited detection of cases in the eastern part outbreaks (Figure 19, Maps 1 and 2).

Cases 50 Arroyo Naranjo

Ciego de Ávila 30

0 Municipalities WEST EAST Weeks 12 to 30 Weeks 31 to 40 Figure 19. Cases of COVID-19 in children and adolescents by municipality, during the first and second evolving epidemic wave. Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database.

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Map 1. Cuba. Cases of COVID-19 by municipalities in population aged 0-18 years. First wave (21 March to 25 July).

NORTH

04 8 kilometres

Cases 10 - 14 5 - 9 2 - 4 1 No cases

075 100 kilometres 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

Map 2. Cuba. Cases of COVID-19 by municipalities in population aged 0-18 years. Second wave (from 26 July to 3 October).

NORTH

04 8 kilómetres

Cases 16 - 34 (1) 10 - 14 (1) 5 - 9 (6) 1 - 5 (17) No cases (128)

075 100 kilómetres 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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In accordance with the territorial heterogeneity of riations ranging from more than 20 per 10,000 people confirmed cases and the differences in the amount of aged 0 to 18 years, to less than one. Differences of si- population aged 0 to 18 years in the municipalities, the milar amplitude are observed in both epidemic waves cumulative incidence rates in weeks 12 to 40 show va- (Figures 20 and 21, Maps 3 and 4).

Rate per 10 000 30 Venezuela 25 Taguasco 20 Regla 15 10 5 0 Municipalities WEST EAST Figure 20. Incidence rates of COVID-19 in children and adolescents by municipality. Cumulative from week 12 to 40. Source: Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database.

Rate per 10 000 20 Taguasco Venezuela 15 Regla 10 5 0 Municipalities WEST EAST Rate in weeks 12 to 30 Rate in weeks 31 to 40 Figure 21. Incidence rates of COVID-19 in children and adolescents by municipality. Comparison of incidence rates in week 12 to 30 and weeks 31 to 40. Source: Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database.

Map 3. Cuba. Incidence of COVID-19 by municipalities in population aged 0 to 18 years. First wave (from 21 March to 25 July).

NORTH

04 8 kilometres

Incidence rate (per 10 000 inhabitants) 10.05 - 16.67 3.21 - 5.58 1.02 - 2.95 0.19 - 0.97 No cases

075 100 Source: Ministry of Health’s daily brie ngs. http://salud.msp.gob.cu/ kilometres 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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Map 4. Cuba. Incidence of COVID-19 by municipalities in population aged 0 to 18 years. Second wave (from 6 July to 3 October).

NORTH

04 8 kilometres

Incidence rate (per 10 000 inhabitants) 6.28 - 15.1 (5) 3 - 5.76 (7) 1.11 - 2.89 (9) 0.6 - 0.89 (4) No cases (128)

A summary of the municipal heterogeneity of the inci- juaní and Caibarién in Villa Clara, Taguasco in Sanc- dence of COVID-19 in children and adolescents shows ti Spíritus and the municipalities of Bauta and San the highest number of cases in the 27 municipalities Cristóbal in the province of Artemisa. These last ones with cases in both epidemic waves. The lowest num- have the highest number of cases in the second wave. ber of cases is recorded by the fifteen municipalities About 10 municipalities register more than 10 total that only reported cases in the first wave, followed by cases and an incidence rate of 10 or more per 10,000 36 that have only confirmed cases in the second wave infected children and adolescents, six of them in Ha- (Figure 22). vana (Table 1). Among the 27 municipalities, there are 15 munici- Table 1. Differences in the number of municipalities and palities from Havana, 4 out of the 8 municipalities of cases in both epidemic waves. the province of Ciego de Avila, the residents of Cárde- RATE PER 10 000 MUNICIPALITIES TOTAL CASES nas and Matanzas in the province of Matanzas, Cama- (WEEKS 12 - 40)

% Venezuela 15 25.13 40 Taguasco 14 21.21 30 Regla 16 18.08 20 Bauta 15 13.89 10 Cotorro 24 13.78 0 Centro Habana 31 13.51 Only in the Only in the In both Camajuani 13 12.42 1st wave 2nd wave waves La Lisa 36 11.97 Municipalities Cases Diez de Octubre 40 11.02 Figure 22. Differences in the number of municipalities and cases in both epidemic waves. Arroyo Naranjo 46 10.67 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.

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1.4. Distribution of children and A comparison between the number of confirmed adolescents (aged 0-18 years) cases in the first and second epidemic waves by type confirmed with COVID-19 by of settlement shows that cases only increased in in the human settlements country’s capital city and in urban towns (Figure 23). The location of cases by place of residence shows that Type of settlement cases have been confirmed among the population aged 0 to 18 in 105 of the country’s 7014 settlements. Country´s capital According to the epidemic waves, the increase in the Cities number of confirmations is visible in a smaller number Urban towns of settlements. In all types of human settlements in the country, contagion has been reported in children and Rural towns adolescents. In cities, 78.9% of all cases have been con- Urban villages firmed (Table 2). Rural villages Hamlets and Table 2. Differences in the number of municipalities and scattered houses cases in both epidemic waves. 0 50 100 150 200 250 Cases STAGES OF THE NUMBER OF CASES First wave Second wave EPIDEMIC SETTLEMENTS Figure 23. Distribution of cases by type of settlement Total 105 637 according to epidemic waves. Source: Ministry of Health’s daily briefings. Department of Week 11 to 30 66 278 Health Surveillance’s Database. Week 31 to 40 49 359 According to settlement categories, in addition to the Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. repeated mention of high transmission in the capital, similar numbers of confirmed residents in settle- About 56.2% of the cases are concentrated in the coun- ments under the category of provincial and municipal try’s capital, where 17% of the total population aged 0 capitals are observed. A lower incidence is observed to 18 lives, which shows its disadvantageous position in other urban settlements and in rural settlements in the spatial evolution of the epidemic. Other cities and population in scattered housing, where less than followed with the highest frequency of cases in ab- 10% of the total cases of the categories was detected solute and relative numbers. Cases reported in cities, (Figure 24). including the country’s capital, represent nearly 80% Settlement 0102030405060 of total registered cases. Rural towns, villages, and sca- category % ttered houses account for a little over 8% of the total Country’s capital number of cases (Table 3). Provincial capitals Table 3. Distribution of cases by type of settlement. TYPE OF AMOUNT OF CASES % Municipal capitals SETTLEMENT SETTLEMENTS Country´s capital 1 358 56.2 Other urban settlements Cities 33 145 22.76 Urban towns 27 67 10.52 Rural settlements Rural towns 2 3 0.47 0 100 200 300 400 Cases Urban villages 11 15 2.35 First wave Percentage Rural villages 24 39 6.12 Hamlets and 7 10 1.57 Figure 24. Distribution of cases by settlement categories scattered houses (quantity and percentage). Weeks 12 to 40. 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.

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The distribution of cases per week shows that from The number of children and adolescents infected week 17 onwards, the detection of cases in the capital with the virus generally falls as the population size city exceeded the rest of the settlements in other ca- of the settlements decreases. However, the smaller tegories, this difference was marked after week 31, ones, with less than 5000 inhabitants, concentrate with the exception week 21, when the number of 13.03% of the total, a figure similar to that of infected cases in municipal capitals are higher. As of week 32, people in settlements between 100,000 and 500,000 the increase in cases in the country’s capital is signifi- inhabitants (Figure 27). cant. (Figure 25). Population 0102030405060 % size Cases 50 More than 500 000

40 From 100 000 to 500 000 30 From 20 000 to 100 000 20

10 From 5 000 to 20 000

0 Less than 5 000 11 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 Epidemiological weeks 0 100 200 300 400 Cases Country´s capital Provincial capital First wave Percentage Municipal capital Other urban settlements Rural settlements Figure 27. Cases according to population size of the settlements. Quantity and percentage. Figure 25. Distribution of cases by settlement categories according to epidemiological week. 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. According to settlements aggregated by population Between the first and second wave of the epidemic, size, a reduction in the number of cases between the the number of cases is generally reduced according to first and second epidemic wave can be observed, and settlement categories with the exception of the capital - only in Havana - a noticeable increase in confirma- city where cases increased. (Figure 26). tions is registered. (Figure 28).

Settlement Population category size

Country´s capital More than 500 000

Provincial capital From 100 000 to 500 000

Municipal capital From 20 000 to 100 000

Other urban settlements From 5 000 to 20 000

Rural settlements Less than 5 000

0 50 100 150 200 250 Cases 0 50 100 150 200 250 Cases First wave Second wave First wave Second wave Figure 26. Distribution of cases by settlement categories Figure 28. Distribution of cases by population size of according to epidemic wave. settlements according to the epidemic waves. 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.

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The location of cases in the population aged 0 to 18 areas, one in the west of the country and another one years by place of residence according to the Index of Hu- in the central and central-eastern part. Municipalities in man settlements, shows the wide distribution of settle- Havana and the municipality of Ciego de Avila report ments with cases during the first wave, and the remar- the highest number of cases in children and adolescents. kable reduction of dispersion in the second wave. This Although cases have decreased in rural settlements, the confirms the limited territorial expression of the second transmission of the virus is evident in neighboring rural epidemic wave, which has been concentrated in two settlements in Ciego de Ávila (Maps 5 and 6).

Map 5. Cuba. Cuba. ocation of children and adolescents confirmed with COVID-19 by settlements. Epidemiological weeks 12-30 (21 March to 25 uly).

Havana: 125 cases

NORTH

Urban cases Rural cases 14 5 7 3 1 1

Settlements

Source: Department of Health Surveillance’s Database, MINSAP 075 100 Index of Human Settlements, ONEI, 2017. ONEI 2017. Digital cartographic database 1:1000 000 Geo Cuba kilometres Author: Luisa Iñiguez Rojas, FLACSO, University of Havana Edgar Figueroa Fernández. CEPDE-ONEI 2017

Map 6. Cuba. ocation of children and adolescents confirmed with COVID-19 by settlements. Epidemiological weeks 31-40 (26 uly to 3 October).

Havana: 233 cases

NORTH

Urban cases Rural cases 25 3 12 2 2 1

Settlements

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Up to week 40, 358 children infected with the vi- tubre, Arroyo Naranjo and Plaza de la Revolución, this rus had been confirmed in Havana. About 339 of them ratio ranges between 57 and 74%. This last municipali- were located with this study. The remaining 17 were ty stands out as one of the municipalities with the least not located because information about the place of in- number of confirmed cases in the province and with fection was not available. the greatest number of neighborhoods registering sick These 339 children were located in 144 of the 415 nei- children (greater dispersion in the municipality). ghborhoods and districts that make up the province for Cases are increasing in areas and population centers 34.70%. The neighborhoods with the highest number belonging to peripheral municipalities of Havana and of reported cases were: Lawton (17), Alamar (11), La Lisa the concentration of cases in the central area in neigh- (10), San Agustin (10) and Regla (10). The Lawton and borhoods from Diez de Octubre and the north of Arro- Alamar districts registered more than 40% of the con- yo Naranjo, and to the west in areas of the municipali- firmed cases in their respective municipalities (Diez de ties Marianao and La Lisa (Map 7). Octubre and Habana del Este). La Lisa and San Agustín, which belong to the municipality of La Lisa, confirmed 1.5 Sources of transmission in 55.55% of the cases in the municipality between them children and adolescents and the old neighborhood of Regla confirmed 62.50% of The distribution by settlements or neighborhoods was the cases in the municipality of the same name (greater used, together with data provided by the epidemiolo- concentration in some neighborhoods). gical observations contained in the databases, in an If we take into account the ratio between the num- initial approach to the processes of virus transmission ber of neighborhoods owned by Havana’s municipali- to children and adolescents. In order to be consistent ties and how many of these ones reported cases, it is with the approach followed in this report, the analy- evident that the most affected municipality is Centro sis was carried out per province, and in some cases per Habana, with confirmed cases in 90.91% of its neigh- municipality, as they represent remarkable examples. borhoods. Likewise, in the municipalities of Diez de Oc- So far, information has been obtained from 81.79% of

Map . avana. Population under 19 years old confirmed with COVID-19. Epidemiological weeks 14-40 (21 March to 3 October).

NORTH

PCR confirmed*

162 34 2.5 0 2.5 5 kilometres Neighbourhood limits Health area limit Municipal limit Reservoirs

Source: Ministry of Health’s daily brie ngs Base: 1:2000 GeoCuba Author: Dra. Luisa Iñiguez Rojas * Fifteen children were not located because the address of the place where they got infected is not available Cartographic writing: BSc. Laura E. Almera Andarcio, (the health areas where the transmission occurred are known). M.Cs. Antonio Herrada Hidalgo

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Source of transmission the cases detected in children and adolescents. In a conventional way, five sources of transmission have Other countries (imported cases) been distinguished: Third parties, including I. Mothers, fathers or both confirmed or asympto- neighbors and other visitors to matic. the household, acquaintances II. Other confirmed cohabiting family members Non-cohabiting relatives (most frequently grandparents). (especially uncles, cousins) III. Non-cohabiting relatives (especially uncles, cou- Other con rmed cohabiting family members sins) (especially grandparents

IV. Third parties, including neighbors and other visi- Mothers, fathers or both tors to the household, acquaintances, classmates, con rmed or asymptomatic friends and others. 0 10 20 30 40 50 % V. Another country (imported case). First wave Second wave Figure 30. Percentage structure of the sources of It has been determined that the main sources of trans- transmission in children and adolescents (=100). First and mission between weeks 12 and 40 correspond to type second epidemic wave. Source: Ministry of Health’s daily briefings. Department of I: mothers, fathers or both, and to type IV, with similar Health Surveillance’s Database. percentages. In a little more than 60% of children and adolescents, the transmission of the virus occurred in almost all of them, infections occurred from other among cohabiting or non-cohabiting relatives. In the non-family members, with higher figures in central first epidemic wave, transmission from a third party provinces during the first wave and in the provin- predominates, with more reiteration from neighbors ce of Matanzas during the second one (Figures 31 and family friends, and from children or adolescents. and 32). In the second, transmission among family members Provinces occurred in about 70% of cases (Figures 29 and 30). Guantánamo The distribution of the types of sources of infec- Santiago de Cuba tion identified by province,4 is heterogeneous, and Granma Holguín 4 The exception is the province of Mayabeque with only one Las Tunas child whose source of infection was undetermined, according Camagüey to the date of available information. Ciego de Avila Sancti Spíritus Source of transmission Cienfuegos Villa Clara Other countries Matanzas (imported cases) Mayabeque Third parties, including La Habana neighbors and other visitors to Artemisa the household, acquaintances Pinar del Río Non-cohabiting relatives 02040160 80 00 % (especially uncles, cousins) Mothers, fathers or both conrmed or asymptomatic Other con rmed Other conrmed cohabiting family members cohabiting family members (especially grandparents) (especially grandparents) Non-cohabiting relatives (especially uncles, cousins) Mothers, fathers or both Third parties, including neighbors and other visitors to the con rmed or asymptomatic household, acquaintances and others. Another country (imported case) 0 10 20 30 40 % Figure 31. Percentage structure of the sources of Figure 29. Percentage structure of the sources of transmission in children and adolescents (=100). First transmission of children and adolescents (=100). Cuba. epidemic wave. 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..

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Provinces living in the municipality of Venezuela was confirmed Guantánamo Santiago de Cuba to have been infected by his father. Granma While in the first epidemic wave, 11 of the 14 con- Holguín firmed cases were infected through primary or se- Las Tunas Camagüey condary contacts of persons arriving from abroad, Ciego de Avila and there was a predominance of transmission from Sancti Spíritus non-cohabiting relatives, in the second wave, hou- Cienfuegos Villa Clara sehold infections are more frequent, mostly from fa- Matanzas thers, mothers or both, and other cohabiting relatives. Mayabeque The reiteration of the household is observed with two La Habana confirmed pediatric cases: Artemisa Pinar del Río ɐɐ 6-year-old twins infected by their cohabiting 02040160 80 00 % grandmother. ɐ Two girls (8 and 12 years old) and an adolescent Mothers, fathers or both conrmed or asymptomatic ɐ (18 years old) infected by contact with a cohabi- Other conrmed cohabiting family members (especially grandparents) ting relative. Non-cohabiting relatives (especially uncles, cousins) ɐɐ Two girls, ages 4 and 6, whose parents were the Third parties, including neighbors and other visitors to the likely source of infection. household, acquaintances and others A 3-year-old girl infected by her non-cohabiting Another country (imported case) ɐɐ grandmother (seamstress), and her brother, a Figure 32. Percentage structure of the sources of transmission in children and adolescents (=100). 12-year-old adolescent, both live together. Second epidemic wave. ɐɐ Two girls, aged 8 and 11 years, infected after con- Source: Ministry of Health’s daily briefings. Department of Health Surveillance’s Database. tact with neighbor confirmed with COVID-19. ɐɐ Two 11-year-old boys and their 11-day-old bro- In the province of Ciego de Avila, the second wave ther, both registered in the same household, and concentrates a high number of cases, only surpas- contacts of their mother who was confirmed sed by numbers in Havana, which shows an intense with COVID-19. transmission. According to the date of confirmation, 57 cases of COVID-19 were detected in children and The second epidemic wave in this province is distin- adolescents from 27 March to 26 September. On 27 guished, in relation to the first one, by the increase in March, a 6-year-old boy resident of the municipality municipalities where cases are confirmed and the hi- of Baragua, was reported, becoming the first indi- gher intensity of the virus spread, according to what genous case in the province. The source of infection happened among the general population of the pro- was recorded in the epidemiological observations as vince, especially in the municipality of Ciego de Ávi- “Contact of asymptomatic traveler from the United la where a little more than 50% of the children and States”. adolescents infected in this province are concentra- The province accumulated 14 cases, the last one con- ted up to the date of this report. Household infections firmed in week 16, during what has been described as from cohabiting relatives are now predominant, as the first epidemic wave in the country. After 138 days the frequency of two children or adolescents being without pediatric cases, on 28 August, a 3-year-old boy infected in one household increases.

-17- Final considerations ɐɐ In the period under study, urban cases predomi- ɐɐ From week 30 onwards, there is an increase in nate, particularly in cities with nearly 80% of the COVID-19 cases among children and adolescents total. In the second wave, the number of cases in in the country. The curve of new cases per epide- provincial capitals increases, and infections con- miological week shapes a second epidemic wave in tinue to be detected in several rural settlements, evolution. especially in the provinces of Ciego de Avila and ɐɐ As it was stated in the previous report, the number Sancti Spíritus, with high incidences. of cases decreases after the epidemic peak from ɐɐ Between the first and second wave, the number of week 15 to 18, and between weeks 22 and 30, only municipalities reporting cases decreased, although 85 cases were detected. the number of cases increased. There are 27 mu- ɐɐ A second epidemic wave, with a progression of 9 nicipalities that have confirmed infected children weeks from week 31 to 40, which is the last one and adolescents in both epidemic waves. Out of the analyzed in this report, already accumulates more 10 municipalities with the highest number of cases than 80 cases in children and adolescents than and rates in the evolution of the epidemic up to those detected in the previous 19 weeks, conside- week 40, six are in the province of Havana, located red as a first wave. in central and peripheral neighborhoods. ɐɐ In the first wave, infected children and adolescents ɐɐ In both epidemic waves, it can be observed as a were detected in all provinces, in the second wave, regularity of the geographical distribution, the cases are reported only in eight of the country’s fif- absence or detection of only few cases in the eas- teen provinces, and 94% of the total is concentrated tern region of the country. The same happens in in only three of them. The territorial expression of the province of Cienfuegos in the central region, the second wave is concentrated in Havana, with and in the western region of Pinar del Rio, as it 65% of the total detected cases, the central province happens with the total confirmed cases in the of Ciego de Avila with 22% and Sancti Spíritus with country. 13%, these provinces had not detected infections in ɐɐ Among the sources of transmission in the epide- children and adolescents until week 30. mic waves described, type I contagion from father, ɐɐ In all age groups studied, between the first and mother or other cohabiting relatives, and type IV second wave, the number of cases increases, parti- contagion from third parties, most often neighbors cularly in the 12-18 age group, with higher numbers and friends of the parents, are the most important. among females. The highest increase is experienced In the second wave, the type I pattern increases by the 0 to 5 age group, in which the rate during the to a little more than 40% of the total and type IV second wave is about double that in the first wave. decreases to 30%.

-18- References Horton, R. (27 de Junio de 2020). The second wave. The el 30 de octubre de 2020, de Johns Hopkins Me- Lancet Journal. doi:https://doi.org/10.1016/S0140- dicine: https://www.hopkinsmedicine.org/health/ 6736(20)31451-3 conditions-and-diseases/coronavirus/first-and-se- Íñiguez, L., Figueroa, E., Almora, L., Germán, A., Herrada, cond-waves-of-coronavirus A., & Somarriba, L. (2020). La COVID-19 en niños y Oficina Nacioanal de Estadísticas e Información. (2019). adolescentes cubanos. Primer reporte, junio 2020. Anuario Demográfico de Cuba. La Habana: ONEI. Obtenido de UNICEF Cuba: https://www.unicef. Oficina Nacional de Estadísticas e Información. (2017). org/cuba/informes/caracteristicas-epidemiologi- Nomenclador de asentamientos humanos. Censo de cas-y-espacialidad-de-la-covid-19-en-ninos-y-ado- Población y Viviendas, 2012. La Habana: ONEI. lescentes Oficina Nacional de Estadísticas e Información. (2020). Íñiguez, L., Figueroa, E., Almora, L., Germán, A., Herrada, Indicadores demográficos de Cuba y sus terrotorios. A., & Somarriba, L. (2020). La COVID-19 en niños y La Habana: ONEI. adolescentes cubanos. Segundo reporte, julio 2020. Shunqing, X., & Yuanyuan, L. (25 de Abril de 2020). Bewa- Obtenido de UNICEF Cuba: https://www.unicef. re of the second wave of COVID-19. The Lancet. doi: org/cuba/informes/covid-19-en-ninos-y-adolescen- https://doi.org/10.1016/S0140-6736(20)30845-X tes-cubanos UNICEF. (agosto de 2020). UNIICEF Data: Monitoring Lockerd Maragakis, L. (14 de Agosto de 2020). First the situation on children and women. (UNICEF, Edi- and Second Waves of Coronavirus. Johns Hopkins tor) Obtenido de UNICEF: https://data.unicef.org/ Medicine. Baltimore, Maryland, USA. Recuperado resources/resource-topic/covid-19/

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