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Letter from Trinidad and Tobago: No final battles in the weary war on COVID‐19?

The coronavirus disease 2019 (COVID-19) was declared a pandemic in March 2020 and has since dominated the global landscape. Trinidad and Tobago (T&T), a twin island nation in the Caribbean with a population of ≈1.4 million people, reported its first case on 12 March 2020. Sixteen months later, T&T has reported 34,765 cases and 937 deaths, with a case fatality rate of 2.70%. T&T faced its ‘first wave’ of cases in September 2020 and is currently in the midst of its second, which began in April 2021. The initial response by the Government (GOVTT) and people of T&T was a laudable success, through engagement in a coordinated response across all levels, including the initial bold step, on 23 March 2020 of closing international borders—the second country to have done so. They are to be reopened on 17 July 2021, representing one of the most prolonged border closures globally. The Prime Minister, Minister of Health and the nation’s Chief Medical Officer (CMO) held frequent press conferences broadcast on all local television channels to update and inform policies and practices. A variety of public health strategies, including mask wearing and segregating positive patients through access to a ‘parallel healthcare system’, were instituted. In addition, a self-quarantine advisory and, soon thereafter, legislation were introduced, limiting workplace interactions only to those designated as essential workers. ‘Face-to-face’ schooling across all levels of education was halted in March 2020 and has yet to resume. Likewise, commercial activities were severely restricted. The Ministry of Health produced daily bulletins across social media, providing statistics on daily and cumulative COVID-19 cases, deaths and hospitalizations. Healthcare experts and epidemiologists appeared regularly at press conferences to advance the logic of the public health interventions and enhance public understanding of strategies to combat the disease. These strategies were announced in The Public Health (2019 novel coronavirus [2019-nCoV]) (No. 4) Regulations, 2020, and supplemented by Legal Notice, No. 66, which permitted the GOVTT to fine and imprison persons in violation of the regulations. The swift, evidence-based approach of the GOVTT to public health measures was widely adopted by the public, resulting in adherence to self-quarantining, social distancing and mask-wearing strategies, with the mantra of the ‘3 W’s’ promoted at the press conferences—‘wash your hands, wear your mask, watch your distance’ becoming national watchwords. Indeed, the CMO has received many accolades and was awarded ‘Individual of the Year’ by one of the country’s leading newspapers in 2020. A relatively high percentage of T&T is employed by the state or agencies of the state such as government ministries or state-owned enterprises, and these institutions immediately instituted ‘stay-at-home’ policies. Additionally, the Ministry of Social Development and Family Services embarked on a number of initiatives to provide financial support for the ensuing social dislocation. The GOVTT proved responsive to changing circumstances utilizing the latest guidelines from the World Health Organization (WHO). Whilst the ‘all-of-government’ approach allowed for rapid containment strategies, the goal of stifling the spread of the disease was ultimately elusive. Despite an official and early closure of international borders, T&T’s ‘second wave’ was characterized by the more transmissible variant, Gamma (P.1), which was first detected in a Venezuelan migrant who may have crossed the border illegally. Insufficient testing has plagued T&T’s COVID-19 response, with only 241,608 tests conducted thus far. During this second wave, there has been a 20.37% positivity rate, implying an under-detection of cases. Thus far, more than 70% of total COVID-19 cases and over 80% of COVID-19 deaths were reported during the second wave. The parallel healthcare system, for all its merits, meant juggling of scarce resources and could not prevent the closure of outpatient clinics and postponement of elective surgical procedures, the consequences of which, although likely to be substantial, have not been satisfactorily computed. Telemedicine, which was first introduced during this period, may become a useful legacy. The authorities may have inadvertently excluded private sector participation in diagnostic testing and management of cases. This may also be the case for the rollout of its immunization programme which requires an ‘all hands on deck’ approach and has achieved a fair measure of success elsewhere. The national vaccination programme began on 17 February 2021, and ≈16.16% of the population has received at least one dose of a COVID-19 vaccine. The vaccination programme has been limited here, as elsewhere, by intense international competition for vaccines. The national policy is to use WHO-approved vaccines, currently being sourced from COVAX, the African Medical Supply Platform and China. Several of these shipments are expected to arrive at T&T in July, with the target of vaccinating half a million people. Vaccine hesitancy has been a global concern, but the recent surge of cases has likely fostered greater public acceptance. Received: 11 July 2021 Accepted: 22 July 2021

The coronavirus disease 2019 (COVID-19) was declared a pandemic in March 2020 and has since dominated the global landscape. Trinidad and Tobago (T&T), a twin island nation in the Caribbean with a population of ≈1.4 million people, reported its first case on 12 March 2020. Sixteen months later, T&T has reported 34,765 cases and 937 deaths, with a case fatality rate of 2.70%. T&T faced its 'first wave' of cases in September 2020 and is currently in the midst of its second, which began in April 2021.
The initial response by the Government (GOVTT) and people of T&T was a laudable success, through engagement in a coordinated response across all levels, including the initial bold step, on 23 March 2020 of closing international borders-the second country to have done so. They are to be reopened on 17 July 2021, representing one of the most prolonged border closures globally. The Prime Minister, Minister of Health and the nation's Chief Medical Officer (CMO) held frequent press conferences broadcast on all local television channels to update and inform policies and practices. A variety of public health strategies, including mask wearing and segregating positive patients through access to a 'parallel healthcare system', were instituted. 1 In addition, a self-quarantine advisory and, soon thereafter, legislation were introduced, limiting workplace interactions only to those designated as essential workers. 'Face-to-face' schooling across all levels of education was halted in March 2020 and has yet to resume. Likewise, commercial activities were severely restricted. The Ministry of Health produced daily bulletins across social media, providing statistics on daily and cumulative COVID-19 cases, deaths and hospitalizations. Healthcare experts and epidemiologists appeared regularly at press conferences to advance the logic of the public health interventions and enhance public understanding of strategies to combat the disease. These strategies were announced in The Public Health (2019 novel coronavirus [2019-nCoV]) (No. 4) Regulations, 2020, and supplemented by Legal Notice, No. 66, which permitted the GOVTT to fine and imprison persons in violation of the regulations. The swift, evidence-based approach of the GOVTT to public health measures was widely adopted by the public, resulting in adherence to self-quarantining, social distancing and mask-wearing strategies, with the mantra of the '3 W's' promoted at the press conferences-'wash your hands, wear your mask, watch your distance' becoming national watchwords. Indeed, the CMO has received many accolades and was awarded 'Individual of the Year' by one of the country's leading newspapers in 2020. 2 A relatively high percentage of T&T is employed by the state or agencies of the state such as government ministries or state-owned enterprises, and these institutions immediately instituted 'stay-at-home' policies. Additionally, the Ministry of Social Development and Family Services embarked on a number of initiatives to provide financial support for the ensuing social dislocation. 3 The GOVTT proved responsive to changing circumstances utilizing the latest guidelines from the World Health Organization (WHO).
Whilst the 'all-of-government' approach allowed for rapid containment strategies, the goal of stifling the spread of the disease was ultimately elusive. Despite an official and early closure of international borders, T&T's 'second wave' was characterized by the more transmissible variant, Gamma (P.1), which was first detected in a Venezuelan migrant who may have crossed the border illegally. 4 Insufficient testing has plagued T&T's COVID-19 response, with only 241,608 tests conducted thus far. During this second wave, there has been a 20.37% positivity rate, implying an under-detection of cases. Thus far, more than 70% of total COVID-19 cases and over 80% of COVID-19 deaths were reported during the second wave. The parallel healthcare system, for all its merits, meant juggling of scarce resources and could not prevent the closure of outpatient clinics and postponement of elective surgical procedures, the consequences of which, although likely to be substantial, have not been satisfactorily computed. Telemedicine, which was first introduced during this period, may become a useful legacy. The authorities may have inadvertently excluded private sector participation in diagnostic testing and management of cases. This may also be the case for the rollout of its immunization programme which requires an 'all hands on deck' approach and has achieved a fair measure of success elsewhere.
The national vaccination programme began on 17 February 2021, and ≈16.16% of the population has received at least one dose of a COVID-19 vaccine. The vaccination programme has been limited here, as elsewhere, by intense international competition for vaccines. The national policy is to use WHO-approved vaccines, currently being sourced from COVAX, the African Medical Supply Platform 5 and China. Several of these shipments are expected to arrive at T&T in July, with the target of vaccinating half a million people. 5 Vaccine hesitancy has been a global concern, but the recent surge of cases has likely fostered greater public acceptance.
T&T entered the pandemic with among the highest rates of chronic, non-communicable diseases (NCDs), that is, obesity, hypertension and type 2 diabetes mellitus globally (unpublished research). The impact of the COVID-19 response on persons afflicted with NCDs has yet to be assessed, but it is likely that disease control and medication adherence would have been negatively affected. This is only aggravated by the unavailability of, and increase in the prices of, chronic disease medications at community pharmacies (unpublished research).
Medical education and training were restructured and adapted to incorporate online teaching strategies. Objective Structured Clinical Examinations (OSCE) and oral examinations were conducted using Zoom video conferencing online software. 6 A 'hybrid' undergraduate medical syllabus was created, whereby the syllabus was taught both online and, after the first wave of cases had ceased, through face-to-face training at the teaching hospitals. However, the second wave necessitated that face-to-face training is postponed.
Compared to other islands in the English-speaking Caribbean, T&T has the highest rate of deaths/1,000,000 population (Figure 1), likely the result of the second wave being driven by the Gamma (P.1) variant, which has been noted to have a higher proportion of severe COVID-19 cases and deaths among younger age groups and patients without comorbidities. 7 Barbados reports the least number of cumulative cases/100,000, and this can perhaps be ascribed to Barbados' vaccination programme, which began early on 15 February 2021, and has since vaccinated the highest proportion of its population among the English-speaking Caribbean.
At the time of writing, T&T was on the downswing of its second wave of cases. The mass vaccination programme is expected to gain momentum soon and with it, hope for emergence from the long, dark shadows of COVID-19!