key: cord-0794398-gan10za0 authors: de Ángel Solá, David E.; Wang, Leyao; Vázquez, Marietta; Méndez Lázaro, Pablo A. title: Weathering the pandemic: How the Caribbean Basin can use viral and environmental patterns to predict, prepare and respond to COVID‐19 date: 2020-04-10 journal: J Med Virol DOI: 10.1002/jmv.25864 sha: dcdab7f3e370b7991d37b4766c3d3ade31094c76 doc_id: 794398 cord_uid: gan10za0 The 2020 coronavirus pandemic is developing at different paces throughout the world. Some areas, like the Caribbean Basin, have yet to see the virus strike at full force. When it does, there is reasonable evidence to suggest the consequent COVID‐19 outbreaks will overwhelm healthcare systems and economies. This is particularly concerning in the Caribbean as pandemics can have disproportionately higher mortality impacts on lower and middle income countries. Preliminary observations from our team and others suggest that temperature and climatological factors could influence the spread of this novel coronavirus, making spatiotemporal predictions of its infectiousness possible. This review studies geographic and time‐based distribution of known respiratory viruses in the Caribbean Basin in an attempt to foresee how the pandemic will develop in this region. This review is meant to aid in planning short‐ and long‐term interventions to manage outbreaks at the international, national and sub‐national levels in the region. This article is protected by copyright. All rights reserved. On March 12, 2020, the World Health Organization (WHO) declared a pandemic of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, the pathogen responsible for the clinical disease known as COVID-19. Governments worldwide have been putting in place measures to limit the spread of the disease, but recent publications 1,2 suggest the pandemic could last up to 18 months. If so, it will be necessary to layer interventions. The reactive control measures employed so far have failed to control the crisis. Countries will have to choose paths of action going forth including a proactive, preventative approach to COVID-19 outbreaks. Proactive planning is challenging when so little is known about SARS-CoV-2. Nevertheless, there is reason to believe the disease will have a predictable spatiotemporal spread based on environmental factors, particularly weather 3, 4 . This knowledge can help countries and regions put measures in place at key points, as is done, for example, with Respiratory Syncytial Virus (RSV) for susceptible populations 5 . Influenza epidemics are likewise treated prophylactically with vaccines for the general population 6 Severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2, is within the taxonomical family coronaviridae. This family of viruses has an envelope, a nucleocapsid, and a positive-sense, single-stranded RNA genome 9 . SARS-CoV-2 is classified into the genus Betacoronavirus, one of four genera within this family 10, 11 . Genome sequencing analyses showed that SARS-CoV-2 is ~30k nucleotides in size, containing a single long open reading frame at the 5' terminal encoding viral replicase/transcriptase and several reading frames for structural proteins towards the 3' terminal, including envelope (E) protein, membrane (M) protein, nucleocapsid (N) protein, and spike (S) protein 11,12 . The surface-located trimeric S glycoprotein is the key determinant of viral host specificity, as it initiates infection by mediating receptor-recognition and membrane fusion 13, 14, 15 . Notably, the S gene of SARS-CoV-2 is highly divergent from other SARS-related coronaviruses, with less than 75% nucleotide sequence identity 11, 16 . Despite significant differences in the S gene sequence, SARS-CoV-2 uses the same receptor as SARS-CoV: angiotensin-converting enzyme 2 11,17 . This suggests some similarities in manner of infection between the two species. Beyond the S protein, other virus and host proteins may contribute to subsequent membrane invagination and pathogenesis, but the molecules and mechanisms are unclear. As the SARC-CoV-2 pandemic evolves, region-specific features may emerge. With confirmation of both direct and indirect transmission routes (via aerosol droplets and fomites, respectively), the central factor underlying viral transmission rate for SARS-CoV-2 is the viral viability while outside the human body 18, 19, 20 . Different regions exhibit unique climate characteristics which are key to the virion decay rates of all respiratory viruses in droplets 21, 22, 23 . One possible explanation is that high temperature and humidity levels lead to inactivation of viral lipid membrane and consequently decrease the stability and transmission rate of virions 18, 24 . While such observations and hypothesis may indicate that SARS-CoV-2 is expected to be better contained in the tropical regions compared to temperate zones, other determinants need to be considered. For example, in warm and humid climates, droplets evaporate less water and are more likely to settle on surfaces. Therefore, if SARS-CoV-2 is predominantly transmitted through touching contaminated surfaces, tropical regions may actually bear a higher risk of outbreak than temperate ones in moments of extreme humidity. This assumption is possible, since the indirect transmission route has been reported to be the important one for several respiratory viruses, including Not all seasonal respiratory viruses experience the same spatiotemporal patterns. Nevertheless, assuming seasonality, the only way of predicting SARS-CoV-2 behavior in a given region is to extrapolate data from known pathogens. Most such studies are based on influenza, which has been extensively studied 32 . A factor that does increase influenza transmission, however, is high precipitation levels in tropical zones. According to some observations 34 For the pandemic, preventive measures have mainly focused on social distancing-a method proven to delay or temporarily stretch out regional outbreaks so as to not overburden healthcare systems 7, 8 . In the case of China, extreme state-enforced social distancing has substantially slowed the epidemic 29 . Multiple countries have followed suit and called for a complete lockdown, halting the economy. As the full blow of the epidemic has yet to reach the Caribbean Basin, it is possible to coordinate methods of social distancing while minimizing the impact to their societies. The same observations can be used to plan for future COVID-19 outbreaks, since the pandemic is expected to last several months, but proper prevention necessitates knowledge of local viral and meteorological trends, and coordination amongst and within nations. Most of the above observations on spatiotemporal patterns and prevention come from influenza, eliciting reasonable concern that data cannot be extrapolated. However, other viruses unrelated to influenza do follow its trends under the right circumstances. RSV is an example of this, as it mimics patterns and transmission routes of influenza in temperate zones 37 and is similarly treated with time-specific prophylactic interventions 45 . Though less studied, trends are also found in coronaviruses, particularly in four endemic strains known to cause respiratory infections: 229-E, HKU1, NL63 Accepted Article and OC43. In Israel, 1,910 samples collected over a single season suggested human coronaviruses (HCoV) closely followed the seasonal patterns of RSV 46 . A 3-year-long Scotland-based study identified a coronavirus peak in the winter months, with a decrease or disappearance of the virus during the summer 47 . Recently, a pattern favoring cold, dry weather was also observed in Hong Kong in a 6-year-long study, though in this case coronaviruses were found yearround 48 Therefore, data from other coronaviruses and the similar portal of infection discussed above do support the idea that SARS-CoV-2 may follow the same patterns as influenza, and that timing interventions around influenza peaks in the Caribbean would be reasonable. This pandemic has already overwhelmed many health systems, but regions that are currently less affected, including the Caribbean Basin, could prepare for the next several months by observing the spatiotemporal behavior of the pathogen's spread. If SARS-CoV-2 interacts with climate and weather as theorized above, it is likely that areas in the Greater Caribbean with Air Surface Temperatures (AST) >25°C and RH>70% might be considered areas of relatively decreased environmental risk (Figure 1 ) 53 . These two variables combined may have the potential of reducing the incidence of COVID-19 for at least parts of the Region. For example, based off recent patterns of heat and precipitation, it would be reasonable for Puerto Rico to expect a higher rate of infection in May-June with a sharp decrease for June-July-August. This follows the trend of influenza over the last 5 years, which in turn follows trends in temperature and precipitation 54, 55, 56 ( Figure 2 ). There is also a seasonal trend for all acute respiratory illnesses to decrease during the warmer months, which will minimize confounding of COVID-Accepted Article 19 with other respiratory syndromes. Currently, Puerto Rico is under an astringent 4-week lockdown; it is unclear when and to what extent restrictions will be lifted. Based on the afore-mentioned trends, some restrictions would need to remain through July to limit outbreaks. Temperature forecasts for the rest of the Caribbean are consistent for the upcoming months: AST is expected to be "warmer than usual" through August 57 (Figure 3) . Presumably this will soften the overall impact of COVID-19 outbreaks. Precipitation forecasts are more variable 58 (Figure 4 ). These forecasts may allow Caribbean jurisdictions to plan for better, smarter public health interventions such as controlling and limiting massive activities, promoting outreach and educational materials, establishing coherent and coordinated lockdowns, promoting voluntary social distancing, increasing production of medical supplies and disinfectants, or closing public gathering spaces to limit the reach of outbreaks. International collaboration is also of essence: a cooperative, transparent system of epidemic vigilance is needed. quality and have documented impacts on respiratory health 73 , though regional tracing of these variables is very limited. As for the indoor environment, now more than ever it is important to address the presence of aeroallergens in homes, as these too are linked to respiratory health 74 . Clinical familiarity with spatiotemporal patterns of aeroallergens and pollutants is therefore advised. The assumption that these seasonal forecasts will predict COVID-19 outbreaks is by any stretch preliminary--it would take years to gather enough data to precise how the virus spreads. Additionally, many variables beyond weather can impact SARS-CoV-2 transmissibility: socioeconomic factors, careseeking behaviors, population density, etc. Intrinsic pathogen factors like Accepted Article mutation rates add another layer of complexity as patterns become a moving target rather than a static picture. Nonetheless, the above approach presuming seasonality makes scientific sense, is consistent with the data available, and is in line with recommendations for several other pathogens. Its use could have a substantial impact in management of this pandemic. Accepted Article Figure 3 . Temperatures will be much warmer than usual in land masses West of Hispaniola, especially Cuba and Belize, and along the coasts of Venezuela and Suriname. They will be mildly warmer than usual in the rest of the Guianas, Hispaniola, Puerto Rico and the Lesser Antilles. Source: Caribbean Regional Climate Center, World Meteorological Association. Temperature Outlook for March-April-May 2020. Available at: http://rcc.cimh.edu.bb/temperature-outlook-march-april-may-2020/. Accessed 22 March 2020. Figure 4 . Precipitation will mildly increase in the insular portion of the Caribbean North-West and the eastern Guianas. The coasts of Venezuela, with its associated islands, and the Leeward Islands are expected to have mildly decreased levels of precipitation. Source: Caribbean Regional Climate Center, World Meteorological Association. Temperature Outlook for March-April-May 2020. Available at: https://rcc.cimh.edu.bb/precipitation-outlook-march-april-may-2020/. Accessed 22 March 2020 1 Ferguson NM, Laydon D, Nedjati-Gilani G, Imai N, Ainslie K, Baguelin M, Bhatia S, Boonyasiri A, Cucunubá Z, Cuomo-Dannenburg G, Dighe A. 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