Carmen Lange

Summary: Background: With more than 50000 accumulated cases, Panama has one of the highest incidences of SARS-CoV-2 in Central America, despite the fast implementation of disease control strategies. We investigated the early transmission patterns of the virus and the outcomes of mitigation measures in the country. Methods: We collected information from epidemiological surveillance, including contact tracing, and genetic data from SARS-CoV-2 whole genomes, of the first five weeks of the outbreak. These data were used to estimate the exponential growth rate, doubling time and the time-varying effective reproductive number (Rt) using date of symptom onset in a Bayesian framework. The time of most recent ancestor for the introduced and circulating lineages was estimated by Bayesian analysis. Findings: A total of 4210 subjects were SARS-CoV-2 positive during the period evaluated, of them we sequenced 313 cases, detecting the circulation of 10 SARS-CoV-2 lineages. Whole genomes analysis identified the local transmission of one cryptic lineage as early as 2 weeks before it was detected by surveillance systems. Analysis of transmission dynamics showed that lockdown reduced Rt and increased the doubling time, however, these measures did not stop the circulation of this lineage in the country. Interpretation: These results demonstrate the value of epidemiological modeling and genome surveillance to assess mitigation strategies. At the same time, an active search for cryptic transmission clusters is crucial to interrupt local transmission of SARS-CoV-2 in a region. Funding: Ministry of Health, Contribution from private donors and Secretaría Nacional de Ciencia y Tecnología. Research in Context: Evidence before this study: In May 2020, we searched for published studies in PubMed and web of Science related to genetic variability and dynamics of SARS-CoV-2 transmission in Latin America, and there was none. On July 2020, there was one study of this type on SARS-CoV-2 transmission in Brazil and none in Central America. We were particularly interested in SARS-CoV-2 cryptic transmission that could allow the virus spread through locals without being detected by respiratory health system surveillance, and no publication was reported. On July 2020, seven papers (five in preprint) were about SARS-CoV-2 cryptic transmission, one in China, another in UK and five in the US. None in Central America. All of them showed the importance of genomic surveillance to detect different lineage introductions, cryptic transmission and its role in early spread in a region or in health-care setting. Added value of this study: We integrate data collected from tested individual during national surveillance of COVID19 suspected cases or contact of cases, as part of the National COVID19 Laboratory network. This data was used to estimate epidemiological parameters of the outbreak as well as the effect of mitigation measures on the epidemic dynamic. We sequence the whole genome of SARS-COV-2 of 7.4% of RT-PCR confirmed cases at the national level, and with phylogenetic analysis we identified SARS-CoV-2 lineages introduced in the country and estimate date of their introductions. Epidemiological and genetic data was compared and we observed the cryptic transmission of one introduced lineage and the rise of a local lineage that was not detected by the active contact tracing implemented by the health system surveillance. This cryptic lineage could explain the fact that early implementation measures decreased the transmission rate and the increased the doubling time, however they were not able to eliminate totally the virus spread. Implications of all the available evidence: This is the first study that analyzed the epidemiology and transmission dynamics of the early COVID19 epidemic in a Central American country using both epidemiological and genomic surveillance. Our findings suggest that strict containment measures and movement restrictions in Panama might have contributed to decrease the early spread of the virus, but that cryptic local transmission allowed a continual basal virus diffusion that could explain, in part, the high incidence of cases in the country. More broadly, our findings are crucial to inform intervention policy in real-time, for countries in similar situations and the importance of constant monitoring of SARS-CoV-2 lineages to understand its transmission in a region.

Background: In view of ongoing pandemic threats such as the recent human cases of novel avian influenza A(H7N9) in China, it is important that all countries continue their preparedness efforts. Since 2006, Central American countries have received donor funding and technical assistance from the U.S. Centers for Disease Control and Prevention (CDC) to build and improve their capacity for influenza surveillance and pandemic preparedness. Our objective was to measure changes in pandemic preparedness in this region, and explore factors associated with these changes, using evaluations conducted between 2008 and 2012. Methods: Eight Central American countries scored their pandemic preparedness across 12 capabilities in 2008, 2010 and 2012, using a standardized tool developed by CDC. Scores were calculated by country and capability and compared between evaluation years using the Student’s t-test and Wilcoxon Rank Sum test, respectively. Virological data reported to WHO were used to assess changes in testing capacity between evaluation years. Linear regression was used to examine associations between scores, donor funding, technical assistance and WHO reporting. Results: All countries improved their pandemic preparedness between 2008 and 2012 and seven made statistically significant gains (p < 0.05). Increases in median scores were observed for all 12 capabilities over the same period and were statistically significant for eight of these (p < 0.05): country planning, communications, routine influenza surveillance, national respiratory disease surveillance, outbreak response, resources for containment, community interventions and health sector response. We found a positive association between preparedness scores and cumulative funding between 2006 and 2011 (R² = 0.5, p < 0.01). The number of specimens reported to WHO from participating countries increased significantly from 5,551 (2008) to 18,172 (2012) (p < 0.01). Conclusions: Central America has made significant improvements in influenza pandemic preparedness between 2008 and 2012. U.S. donor funding and technical assistance provided to the region is likely to have contributed to the improvements we observed, although information on other sources of funding and support was unavailable to study. Gains are also likely the result of countries’ response to the 2009 influenza pandemic. Further research is required to determine the degree to which pandemic improvements are sustainable.