COVID-19 in T&T – Tracking the Data [Part 2]

Over the last week, the Ministry of Health has become more forthcoming with data concerning our COVID-19 cases, contact tracing, and the sample breakdown of samples submitted to the Caribbean Public Health Agency.

Since the first case of COVID-19 in T&T, we have been scraping as much data as is available to give you a look at the situation – leaving politics and rhetoric out of it.

With the most recent release of data from the Ministry of Health (on April 19th, when we still had 114 confirmed COVID-19 cases), there have been some glaring inconsistencies ranging from a difference in our total number of cases, to the dates in which COVID-19 cases were announced, to the ages and sex distribution of the patients.

COVID-19 Cases in T&T

Our first case of the novel coronavirus was an imported case, confirmed on March 12th, 2020.

Note that the data we’ve used all originated from the Ministry of Health Press/Media Releases, which are accessible from the Ministry of Health’s Twitter and Facebook feeds. The data presented in the below charts in this section originate from the Epidemiology Division of the Ministry of Health.

The Epidemiological Curve

Based on the epidemiological curve (reproduced below) presented by Dr. Avery Hinds, Technical Director in the Epidemiology Division at the Ministry of Health, on April 19th, 2020, their data shows that our first case was reported on March 11th.

The epidemiological curve (reproduced below) presented by Dr. Avery Hinds, Technical Director in the Epidemiology Division at the Ministry of Health, on April 19th, 2020.

However, given the timeline of events presented by the Ministry of Health on March 12th, the positive COVID-19 test result came back from CARPHA the afternoon of March 12th.

Trinidad and Tobago’s total of cases has been inflated by nationals who were stranded on the ill-fated Costa Favolosa cruise where an outbreak of COVID-19 occurred. Based on all previous timelines presented by the Ministry of Health, 68 nationals were repatriated and immediately sent into quarantine on March 17th into Camp Balandra, with 40 people testing positive on March 21st.

However, based on the above curve, our first case that originated from the Costa Favolosa cruise was on March 18th. Outside of the group of 40 that tested positive (MOH Update #39), it took two days for cases beyond the “initial” 40 to be reported on the daily press releases (MOH Update #43).

Press releases from the Ministry of Health announcing the 40 people who tested positive for COVID-19 resulting from the group at Camp Balandra initially on March 21st (Update 39) and the next most recent press release (Update 43) announcing the first case of COVID-19 from the cruise cohort that did not arrive with the Balandra 68.

Based on data collected from the two to three daily press releases from the Ministry of Health since our first COVID-19 case in Trinidad and Tobago and the epidemiological curve, which is also from the Ministry of Health, the numbers are not aligning, as seen in the below graph.

Comparing the daily increases in COVID-19 cases based on the Ministry of Health’s 2-3 daily press releases and the epidemiological curve presented on April 19th, 2020 by the Ministry of Health Epidemiological Division.

Reiterating: All of this data and comparison are valid up to 10 AM on April 19th, 2020. At that point, Trinidad and Tobago officially had recorded 114 confirmed COVID-19 Cases, with the 114th case, confirmed in the 10 AM Update (#106) Wednesday 16th April 2020.

However, when you look at the cumulative number of cases from the Ministry of Health’s press releases versus the Epidemiological Division’s data, up to April 14th, based on their total, we already had 115 cases.

One possible explanation for this date discrepancy – the epidemiological curve (though it does not explicitly state on its x-axis) is tracking the date of symptom onset. This would mean inherently, the epidemiological data would always be earlier in showing cases than the daily press release.

What this does not explain is why on April 14th, the epidemiological curve showed 115 COVID-19 cases, while up until 10 PM April 14th, we only had 113 publicly reported cases – this increased to 114 on April 15th at 10 AM and 115 officially at the 4 PM update on Tuesday 21st April 2020.

Comparing the cumulative number of COVID-19 cases in Trinidad and Tobago based on the data presented by the Ministry of Health’s Epidemiological Division versus the information presented in the Ministry of Health’s daily press releases since our first publicly known COVID-19 Case.

The Demographic Data

On April 11th, the Ministry of Health first released the demographic data for COVID-19 patients in Trinidad and Tobago up until April 10th. At that point (10 PM, Friday, April 10th, 2020), Trinidad and Tobago had recorded 109 cases of COVID-19 in the country with eight deaths. The male-female breakdown reflected that total exactly.

Demographic data from the Ministry of Health as of 10:00 AM Saturday 11th April 2020 showing the age and gender breakdown of (at the time) 109 confirmed COVID-19 cases in T&T. At the time of publishing, T&T has 46 male and 63 female COVID-19 patients.

Trinidad and Tobago’s youngest COVID-19 patient at the time was a 5 to 9-year-old male and the eldest patients consisted of two females and one male that falls within the 80-84 age bracket. The gender distribution in the country shows that, based on the April 11th data, COVID-19 has infected 46 males versus 63 females. This is anomalous compared to global data, which shows males are disproportionately affected.

All eight deaths across both islands were patients aged 55 and older, though no gender distribution was given for the deceased.

Demographic data from the Ministry of Health as of 10:00 AM Saturday 11th April 2020 showing the age breakdown of (at the time) 8 COVID-19 related deaths in T&T.

On April 19th, the epidemiological division published its update. Note at this point, at 10 AM Sunday 19th April 2020, Trinidad and Tobago had recorded 114 cases of COVID-19. It is also important to note that these statistics, presented by Dr. Avery Hinds of the Ministry of Health’s Epidemiological Division were supposed to represent the data as current at that day and time.

Not only did the number of males and females did not match this total, but inexplicably, several persons seemed to have switched age brackets and switched sexes. The total number of persons based on the demographic breakdown on April 19th – 109.

Demographic data from the Ministry of Health as of 10:00 AM Sunday 19th April 2020 showing the age breakdown of COVID-19 Patients.

Reiterating, the above charts are supposed to be representative of all COVID-19 cases (deaths, recovered, active cases) at the respective times, meaning that the more recent chart should have had 5 more people added overall.

Instead, for the males, the following were added: a 30-34-year-old, two 40-44-year-olds, a 55-59-year-old, and a 60-64-year-old. The following males were also somehow removed from the demographics: one 45-49 year old, one 50-54 year old, and two 65-69-year-olds.

Similarly, for the female breakdown, the following were added: a 35-39-year-old and two 65-69-year-olds. The following females were also removed from the demographic breakdown: a 40-44-year-old, a 50-54-year-old, a 55-59-year-old, and two 60-64-year-olds.

Another possible explanation for this shift in data, either the initial or new set of data is incorrect – given the drastic change in the age and sex distribution, as well as the non-change in numbers.

COVID-19 Testing in T&T

Testing has been a contentious topic in Trinidad and Tobago, with only legitimate testing being carried out by the Caribbean Public Health Agency (CARPHA). However, while Trinidad and Tobago, as well as a number of other CARICOM member states, submit swabs to CARPHA for testing, not all of these swabs have been accepted.

The Testing Procedure

This is based on information provided by the Chief Medical Officer, Dr. Roshan Parasram during the April 18th, 2020 Media Conference.

  1. A patient presents themselves to a health facility with signs and symptoms that meet the clinical case definition, as defined by CARPHA. Note that this continues to change as the epidemic progresses. (If a patient cont
  2. If the patient meets the case definition, a nasopharyngeal swab will be taken from the patient’s nasopharynx by medical officials.
  3. This swab will be transported to the Trinidad and Tobago Public Health Lab. It is then transferred to CARPHA – the regional reference lab for testing for COVID-19.
  4. CARPHA would then decide, based on the clinical case definition, if a sample is rejected or not. If it is not rejected, it goes onwards for testing via the COVID-19 RT-PCR test, a real-time reverse transcription-polymerase chain reaction. This is the gold standard for testing as it is highly sensitive and specific in testing for COVID-19.
  5. It takes approximately 24-48 hours for test results to be produced by CARPHA, which is only sent to the Chief Medical Officer at the Ministry of Health.
CARPHA's COVID-19 Case Definitions as of April 6th, 2020.
CARPHA’s COVID-19 Case Definitions as of April 6th, 2020.

What if you call the Ministry of Health’s hotline, or your respective County Medical Officer of Health? This is based on information provided by the Chief Medical Officer, Dr. Roshan Parasram during the April 21st, 2020 Media Conference.

  1. If a person calls in and they are flagged as a suspected case, the information goes straight to the Principal Medical Officer of Epidemiology.
  2. The Principal Medical Officer of Epidemiology would then make contact with the County Medical Officer of Health who would liaise with the suspect case directly within 24 hours.
  3. Arrangements would be made if the suspect case has to be swabbed.
  4. If swabbed, that sample would be transported to the Trinidad and Tobago Public Health Lab, which will follow the above procedure.

Note that CARPHA will not send results to any patient or individual as the Agency considers this an ethical breach and constitutes a violation of the Agency’s ethics to share patients confidential information with unauthorized persons.

Surveillance Testing

The following is based on information provided by the Chief Medical Officer, Dr. Roshan Parasram during the April 14th, 2020 Media Conference.

Surveillance testing is not a new scenario for Trinidad and Tobago. It is usually done by the Surveillance Department within the Ministry of Health for several years.

It is done to determine what kind of viruses are circulating at any given time and was done when H1N1 was prevalent. It would also indicate if people outside the case definition for COVID-19 test positive for the disease.

For COVID-19, the Ministry of Health is conducting a random sampling of persons who meet the case definition for Acute Viral Illness (AVI). One sample per day is selected by a physician from each of the 9 health centers within each county of Trinidad, as well as Tobago and sent for testing.

These samples would be labeled differently from other samples so that CARPHA will not reject it. First surveillance samples were taken on April 14th, 2020 and as of April 22nd, 2020 – all 63 surveillance samples to date have come back negative for COVID-19.

Other Testing Methods

The Ministry of Health is looking into drive-through testing as what we currently get in health care facilities are the more severe cases. With 80% of COVID-19 cases being mild – meaning a sore throat or mild symptoms for one day and a return to normal, the Ministry is attempting to capture these milder cases. However, they state that individuals would have to be pre-screened to meet the case definition.

With regards to using antibody tests, the Ministry of Health has maintained that PCR testing remains the gold standard for now, with antibody tests not producing the desired sensitivity and specificity required for a true positive or a true negative test.

Have we missed cases of those who may have already died? According to the Minister of Health and the Chief Medical Officer, the CMO has not seen an increase in unexplained deaths due to any viral illness, including H1N1 or Influenza B. The CMO has also stated there is no data that shows an increase in severe acute respiratory illnesses, which is one of the things they look for. In addition, the CMO has also stated he has not seen any increase in deaths due to pneumonia.

However, keeping with international best practices, autopsies will not be done on COVID-19 deaths due to the risk of spread. Autopsies will be carried out as normal on all other patients. Cremations and burials can happen, but cremations must occur in a crematorium.

Breaking Down The Ministry of Health Press Release

Ministry of Health Media Release concerning COVID-19 in T&T  - Update #129 as of 10:00 PM Wednesday 22nd April 2020
Ministry of Health Media Release concerning COVID-19 in T&T – Update #129 as of 10:00 PM Wednesday 22nd April 2020

The Total Number of Samples Submitted

The total number of samples submitted has been a hotly debated number as there were concerns of this figure including rejected samples by CARPHA as well as the multiple retests needed for discharge.

However, the Ministry of Health has clarified that the number of samples submitted only includes the samples accepted by CARPHA for testing – including both individual, unique samples, as well as repeats. It does not include rejected samples.

Starting on April 21st, for the 10 AM updates only, the Ministry of Health has provided the breakdown of submitted samples. At 10 AM April 21st, of the 1380 submitted samples, 1157 were unique while 223 were retests. At 10 AM April 22nd, of the 1425 submitted samples, 1195 were unique while 230 were repeated.

As of April 16th 2020, the CMO estimated that just over 50 samples have been rejected. The two main reasons for rejected samples are that either the sample is not adequate or it does not meet the clinical case definition for testing.

Data from the Ministry of Health daily press releases and updates containing the number of samples submitted to the Caribbean Public Health Agency (CARPHA) for testing for COVID-19. Note that these figures show the number of samples submitted by the Regional Health Authorities to CARPHA across Trinidad and Tobago, including both unique and repeated samples. It does not include rejected samples.

Number of Samples Which Have Tested Positive For COVID-19

Though the name suggests this would include retested positives, the CMO has assured this number only includes the number of uniquely positive samples – hence it can be used as the number of COVID-19 cases n T&T.

Number of Persons Discharged

For a patient to be discharged, they would have to be symptom-free and have two negative COVID-19 test results within 24 hours. This means that the patient would have recovered from the virus. Hence, discharged and recovered can both be used.

When a patient is discharged, they are asked to quarantine for another 7 days once returning home.

Today’s COVID-19 Cases in T&T

Confirmed positive COVID-19 cases, deaths, and recoveries in Trinidad and Tobago. Data: Ministry of Health, Trinidad and Tobago. This chart will be updated daily.

As of Wednesday night, 22nd April 2020, Trinidad and Tobago has recorded 115 confirmed COVID-19 cases, 8 deaths, and 37 recoveries (discharged). 1454 samples have been submitted to the Caribbean Public Health Agency for testing.

While it is not entirely clear the number of cases that are classified as local, imported or community spread, 52 positive cases have originated from one cluster – the Costa Favolosa cruise. 49 of these cases have stemmed from 68 nationals that have been quarantined at Camp Balandra while 3 additional cases were nationals who returned to T&T separately.

As of April 22nd, 2020, Trinidad and Tobago has been classified as a country with sporadic cases or sporadic spread. According to CMO Dr. Roshan Parasram, this means we have cases related to travel (imported cases) and a couple of local cases (primary contacts of those who traveled), but there is no mass community spread at this point.

Where are the COVID-19 cases coming from?

Again, before you read further, we’d like to ask you to ask yourself what would you do differently if you saw there was a COVID-19 case that originated in your community? You should have already been practicing the best hand and personal hygiene, social distancing, and staying inside and at home, whether a case originated in your neighbourhood or not.

When we say a case originated, it means that the COVID-19 positive person lived in this neighborhood before being quarantined at a medical facility. Based on current regulations and national policy, if you test positive for COVID-19, you will be institutionalized at Caura Hospital or at the Couva Hospital. This is not only to provide patients with the best level of care but to also decrease the risk of spreading within their household or community. You cannot quarantine at home.

Remember, most cases to date in Trinidad and Tobago were imported, any COVID-19 positive cases were isolated and hospitalized upon a positive test so there would be a lower risk of spread. Primary contacts of COVID-19 positive patients were also advised to quarantine, or self-isolate if ill.

Regardless, the CMO Dr. Roshan Parasram said it best, the only way to stop the spread of this disease is to “treat everyone as if they are COVID-19 positive.”

This geographical data came from the release from the Ministry of Health’s press conference on April 19th, showing both the demographic data and locations of the laboratory-confirmed cases of COVID-19 until 10 AM April 19th.

To create these maps, we georeferenced the data points from the Ministry of Health’s map to look at the data at a community-level.

Northwestern Trinidad

Laboratory confirmed COVID-19 cases across Northwestern Trinidad. Data: Ministry of Health
Laboratory confirmed COVID-19 cases across Northwestern Trinidad. Data: Ministry of Health.

Across Northwestern Trinidad, as of April 19th, 2020, 17 COVID-19 cases originated from this area.

In Blue Range and Malick, two COVID-19 cases originated in each community respectively. Across Carenage, Blue Basin, Petit Valley, La Pastora, Never Dirty, Gonzales, Morvant, East Port of Spain, Eastern Quarry, Laventille, Barataria, San Juan, and Valsayn, one case was reported in each community.

North-Central Trinidad

Laboratory confirmed COVID-19 cases across North-Central Trinidad. Data: Ministry of Health.
Laboratory confirmed COVID-19 cases across North-Central Trinidad. Data: Ministry of Health.

Across North-Central Trinidad, as of April 19th, 2020, 16 COVID-19 cases originated from this area.

In the Dinsley/Trincity area, 3 COVID-19 cases originated from that community. Two cases came from Arouca, Red Hell, O’Mera, and Malabar respectively. One case came from El Dorado, Five Rivers, Tacarigua, Maloney Gardens, and La Horquetta.

Northeastern Trinidad

Laboratory confirmed COVID-19 cases across Northeastern Trinidad. Data: Ministry of Health.
Laboratory confirmed COVID-19 cases across Northeastern Trinidad. Data: Ministry of Health.

Outside of Camp Balandra in Rampanalgas, there are no confirmed COVID-19 cases in the region. As of the 19th April, 2020, 49 (forty-nine) cases originated from the group of 68 nationals. All of the 68 nationals have left the Camp Balanadra site as of April 22nd, 2020.

West-Central Trinidad

Laboratory confirmed COVID-19 cases across West-Central Trinidad. Data: Ministry of Health.
Laboratory confirmed COVID-19 cases across West-Central Trinidad. Data: Ministry of Health.

Across West-Central Trinidad, as of April 19th, 2020, 13 COVID-19 cases originated from this area. This includes four from the Longdenville area, two from Point Lisas and one each from Charlieville, Cunupia, Las Lomas, Palmiste, Edinburgh 500, Spring Village and Brechin Castle.

Southwest-Central Trinidad

Laboratory confirmed COVID-19 cases across Southwest-Central Trinidad. Data: Ministry of Health.
Laboratory confirmed COVID-19 cases across Southwest-Central Trinidad. Data: Ministry of Health.

Across Southwest-Central Trinidad, as of April 19th, 2020, 9 COVID-19 cases originated from this area.

This includes two cases each from the Golconda area as well as Palmyra/Mount Stewart Village respectively. One case each also originated from Palmiste, Picton, Corial Village, Green Acres, and Union Village.

Southern Trinidad

Laboratory confirmed COVID-19 cases across Southern Trinidad. Data: Ministry of Health.
Laboratory confirmed COVID-19 cases across Southern Trinidad. Data: Ministry of Health.

Across Southern Trinidad, as of April 19th, 2020, 5 COVID-19 cases originated from this area.

This includes two from Penal and one each from Barrackpore, De Gannes Village and Cap-De-Ville.

Tobago

Laboratory confirmed COVID-19 cases across Tobago. Data: Ministry of Health.
Laboratory confirmed COVID-19 cases across Tobago. Data: Ministry of Health.

Across Tobago, as of April 19th, 2020, 5 COVID-19 cases originated from this area.

This includes two from Moriah and Black Rock respectively, with one originating from Easterfield.

What about East-Central and Southeastern Trinidad?

To date, there are no confirmed COVID-19 cases originating from either of these regions in Trinidad.

However, over 715 contacts have been traced from COVID-19 positive patients, including primary, secondary, and tertiary contacts – some of which reside in eastern areas of Trinidad. The Ministry of Health continues to ask those persons to remain home.

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