by Pedro De Jesús López Acosta
A CLARIFICATION FOR THE DISTRUSTFUL: If I decided to write this text, it’s not because I’m not proud of what our medical personnel do, regardless of what their task is, to fight the COVID-19 epidemic; it’s not because I don’t acknowledge the efforts our government carries out to minimize the disruptions of all kinds that this critical event causes in each of our lives and the country’s; it’s not because I underestimate anyone’s work, or anyone’s intelligence, or anyone’s love poured into being helpful in this trying moment. I do it because I believe information and communication have not been up to the standard of everything else.
Nobody —whether friend or enemy of the people and the Cuban Revolution— paid for the significant amount of mobile data services I used for nearly a week so as to search for materials from many different and reliable sources that would allow me to go deeper into a subject in which I’m not a specialist, but which has strained my intellectual energies, persistently, since late March.
It’s clear that this text I now share may have mistakes. I worked very hard, however, so that it wouldn’t. I’ll risk publishing it, nevertheless, because I honestly believe in its usefulness, in spite of the fact that a great deal of what is said here was communicated to the Ministry of Public Health (MINSAP) via the email address email@example.com and I didn’t even get an acknowledgment of receipt. Anyone unwilling or unable to think is advised not to read it.
When a person who suffers from a contagious disease (or carries the agent that causes it) enters a country and is diagnosed there, he or she becomes, in the language of epidemiology, an IMPORTED CASE, because, as it happens with goods, the germ has crossed the national borders.
That person —foreign or not—, in turn, may infect other people who live in the country where he or she has arrived. And they, in turn, may infect others… For such cases, epidemiologists use the term LOCAL TRANSMISSION, because contagion occurs within the country, and who infected who can be determined. Lastly, there may come a time in which it is impossible to reconstruct the transmission chains of the disease. In that situation, one speaks of COMMUNITY TRANSMISSION.
Now, these are not the only terms used by epidemiologists, government officials, and journalists throughout Spanish-speaking countries.
Cases acquired by local transmission, with strong epidemiological evidence that directly links them to a known imported case (first-generation local transmission), may be designated as INTRODUCED CASES —I don’t understand very well why (the word ‘introduced’ would seem more appropriate for imported cases, since ‘to import’ is ‘to introduce’). And community transmission is also known as NATIVE TRANSMISSION, and, far less frequently, INDIGENOUS TRANSMISSION.
(It’s worth noting that INTRODUCED CASES is not the same as INDUCED CASES. The latter are those who are infected by way of used needles, during childbirth or through blood transfusions; and, therefore, have nothing to do with the forms of infection of COVID-19.)
It is evident that the basis for the nomenclature formed by the terms IMPORTED CASE, LOCAL TRANSMISSION and COMMUNITY TRANSMISSION —which is endorsed by the WHO— is both the place where the infection starts and the identity of the source that produces it. That’s why, on the one hand, ‘imported’ is used in opposition to ‘local’ and ‘community’, since the origin of the first one is outside the country (ex situ) and the origin of the other two is inside (in situ). On the other hand, ‘imported’ and ‘local’ oppose ‘community’, since in the first two cases it is possible to reconstruct the transmission chains, and in the latter case it is not.
It’s important to point out that the term LOCAL TRANSMISSION is not equivalent to the very similar term LOCALIZED TRANSMISSION, which assesses or quantifies the lesser degree in which transmission of a pathogen has spread in a given country, as opposed to the greater degree, which is EXTENDED TRANSMISSION or GENERALIZED TRANSMISSION.
Thus, in certain areas of Matanzas, Consolación del Sur and, now, the Plaza de la Revolución municipality, there has been a LOCALIZED TRANSMISSION; and the quarantine or isolation measures which have been declared in the last two cases are precisely trying to contain the spreading of the virus outside these areas. In the term LOCALIZED TRANSMISSION, the modifier ‘localized’ is synonymous with ‘circumscribed’, ‘restricted’, ‘limited’, etc. It must not be confused —as has been done, from the beginning, by health authorities and the press— with LOCAL TRANSMISSION, a term which does not assess or quantify the degree of spreading of a pathogen, but describes the way in which it is being transmitted, taking into account the characteristics of the sources of infection.
This doesn’t mean, let’s be clear, that there’s no local transmission in the above-mentioned areas. It exists because there are positive cases in all of them which are derived from a previous infection coming from an imported case. However, it’s a mistake to state —as it happened on March 27— that ‘the first event of local transmission in the country occurred in the province of Matanzas’, or maintaining —as it happened on March 30— that ‘the second event of local transmission occurred in Cuba’ because ever since the dancer from Santa Clara —the fourth case that was confirmed in the country, on March 12— was infected by his Bolivian wife, there is LOCAL TRANSMISSION in Cuba, this being the standard term used by the WHO and which the MINSAP should use. And after that day, cases of local transmission were reported on March 16, 20, 21, 22, 24, 25, 26, etc. Consequently, the term which describes the epidemiological situation in the areas of Matanzas, Consolación del Sur, and Plaza de la Revolución is not LOCAL TRANSMISSION, but LOCALIZED TRANSMISSION, because what’s important to highlight is not the characteristics of the sources of infection or the manner of contagion, but the magnitude and intensity of the infectious outbreak taking place there, in comparison with the rest of the local transmission cases in the country.
The way in which the standalone term TRANSMISSION has been used is very confusing.
We can use as an example these literal transcriptions of two statements by MINSAP authorities:
- ‘We cannot say that there’s transmission in Cuba (…) Transmission is when we begin to find people we can diagnose with the presence of the virus, with or without symptoms, and who, however, have had no relation with any person who has arrived in the country carrying the disease. Then we will be able to say that there is a transmission of the disease.’ (Mesa Redonda, 17/3/2020)
- ‘In this community in Consolación del Sur, which is, moreover, a specific area (…) and starting with a confirmed case related to a foreign source, well, we have already diagnosed 5 more people who were infected by that case. That indicates that in that location, in a circumscribed manner, there was a transmission of the disease from that person who arrived sick to the other people who had been in contact (…)’ (Press conference, 1/4/2020)
In statement 1, the existence of transmission is made dependent on not finding any link to an imported case in the transmission chain (‘person who has arrived in the country carrying the disease’), while in number 2, the opposite is maintained: ‘there was a transmission of the disease’ from the confirmed case which infected 5 people. But this confirmed case was ‘related to a foreign source’, that is, with an imported case.
The common case is that TRANSMISSION constitutes a reduction of the term LOCAL TRANSMISSION, making an ellipsis of the adjective ‘local’. This use of TRANSMISSION is usual in the televised reports by MINSAP about COVID-19, where there’s a common reference to the amount of ‘countries reporting transmission’, according to the daily report issued by the WHO, based on the data it receives from each nation’s health authorities.
By the way, beyond the mere confusion of terms, there a problem of mismanagement of data in the fact that the first 40 positive cases in Cuba were reported to the WHO as IMPORTED CASES ONLY, when, I repeat, since the fourth case we already had local transmission (cf. report 64 of the WHO of March 24, 2020, at https://www.who.int/…/novel-coronavirus-2…/situation-reports).
To round off, in the data board Covid19CubaData —developed by the magazine Juventud Técnica, in cooperation with the School of Mathematics and Computing of the University of Havana and the Postdata Club project—, which publishes information from official national sources, the case breakdown is done following a different nomenclature.
Instead of LOCAL TRANSMISSION, Covid19CubaData uses INTRODUCED CASES; and COMMUNITY TRANSMISSION is called NATIVE CASES. These labels do not correspond with the ones used by the WHO for the presentation of global COVID-19 statistics, or with the ones our health authorities and press media have regularly used since the beginning of the epidemic in Cuba, in such a way that their use generates a terminological duplicity which might affect communication. On the other hand, INTRODUCED CASES are the ones that result from a specific type of local transmission, first-generation ones, whose direct link to a known imported case must be unequivocally established. In this category, there’s no room for second-generation local transmission cases, such as, for example, the ones of the Varadero tourism entertainment host’s girlfriend and girlfriend’s father, who, however, erroneously appear quantified under that label.
If using several terms to designate the same reality is bad, using none at all is sometimes worse.
In the daily reports by MINSAP (they can be consulted at https://salud.msp.gob.cu), specifically starting with the one issued at the end of March 30, the statistic of confirmed Cuban patients is set out without resorting to any of these specialized terms. Thus, they are divided into patients who:
- have a source of infection abroad;
- are contacts of confirmed cases;
- are contacts of travelers coming from abroad.
If you’ve read carefully this far, you will infer that number 1 is equivalent to IMPORTED CASES. Those in groups 2 and 3, however, seem to be associated with LOCAL TRANSMISSION, although there’s a substantial difference between them.
After comparing the numerical data and the details that MINSAP offers daily about each of the newly confirmed patients, I deduce that group 2 includes not only the people who are directly infected by an imported case (first-generation local transmission), but also the ones who are not directly related to it, yet are a part of its chain of contagion within the country. On the other hand, COVID-19 positive cases in group 3 are people presumably infected by travelers who are in the country and are not confirmed cases (some don’t even show symptoms at the time of the report), or either they are already outside Cuba and their health status cannot be determined, and sometimes not even their exact identity. The statistics also include in this group —inexplicably and forcibly— some cases (6 in total) about which there’s no epidemiological reference in the official reports. Here I reproduce three:
‘68-year-old Cuban citizen, from Plaza municipality in La Habana province. She started showing symptoms last March 24, being admitted with pneumonia to the IPK. 15 contacts of this patient are under watch.’
‘42-year-old Cuban citizen, from Centro Habana municipality in La Habana province. She was admitted to the Luis Díaz Soto Hospital. Her evolution is satisfactory until this moment.’
‘73-year-old Cuban citizen, from Matanzas municipality in the province of the same name. He was admitted to Mario Muñoz Monroy Hospital on March 31. His evolution is satisfactory until this moment.’
The cases in group 3, and especially those whose details I have literally quoted from the MINSAP reports, are supposed local transmission cases and, precisely due to their presumptive, unconfirmed nature, some might be interpreted —in my opinion— as cases of COMMUNITY or NATIVE TRANSMISSION. They add up to 40 between March 30 and April 4. That’s not counting some similar ones which are listed in the information from March 28 and 29, as well as others at the end of yesterday, April 5, ‘with an unspecified source of infection’, an expression which appears for the first time in a report.
Perhaps someone might think that not resorting to the specialized terminology in the daily reports facilitates comprehension for the majority of the public. However, I believe the contrary is true. That the statistics do not rigorously correspond with the categories established by the WHO, or with the ones the health authorities themselves and the national news media have favored since the beginning of the epidemic in Cuba, generates noise in communication, because, among other issues, it increases the lack of homogeneity in the presentation and interpretation of the data.
And the result is that, in spite of the efforts being made to provide news coverage about COVID-19 in our country, beyond the total numbers of infected cases and deaths, we do not have a clear idea of the advance of the epidemic, particularly because of the words of the health authorities —and, therefore, those of the press— do not coherently present or interpret it.
In that sense, a grave communicative problem occurred when, on Saturday, March 28, MINSAP’s national head of Epidemiology stated that Cuba had entered the epidemic phase; and on Sunday, March 29, the Minister of Public Health, barely even alluding to the statements of the previous day, maintained that the country remained in the pre-epidemic phase.
But this matter —the terms used to designate the different stages of an epidemic in Cuba and the world— would merit individual analysis.
Translated from the original