Update 7th September 2020:   On 4th September, the  CDC revised their alert for St Kitts and Nevis to “No Travel Health Notice: COVID-19 risk is very low.” We applaud this revision as this more accurately reflects the current COVID-19 risk in St Kitts and Nevis. 

On 6^th August 2020, the CDC issued a Level 3 warning alert with regards to St Kitts and Nevis and its COVID-19 risk. According to the CDC’s website, a Level 3 warning indicates that the COVID-19 risk is high in St Kitts and Nevis and because of this risk, they recommend that travellers avoid all non-essential travel to the twin-island state.

Upon hearing this alert, we and most of St Kitts and Nevis were baffled. Currently, St Kitts and Nevis has no active cases of COVID-19 and to date has only had 17 cases, with no deaths and no community spread, all cases were travel-related.

To try and understand why the CDC assigned this Level 3 classification to St Kitts and Nevis, we reviewed how the CDC determines its Travel Health Notice Levels for COVID-19 and this is provided below:

*********

* All criteria are assessed over the last 28 days (2 incubation periods for COVID-19).

Secondary Criteria are qualitative and come from official destination sources (e.g., ministry of health websites).

• Measures of a destination’s healthcare capacity, such as available hospital beds and ventilators.
• Measures of a destination’s public health infrastructure, such as testing capacity, contact tracing capacity and documented exported cases (cases identified in travellers to other countries).

Notes:

• Destinations that fall below the Level 1 primary criteria and meet secondary criteria have no THN.
• Destinations can only de-escalate if their new case count is decreasing or stable.

*********

When we compare the above criteria with the data from St Kitts and Nevis, we see the following:

• In the 28 days leading up to the CDC issuing the Level 3 alert, St Kitts and Nevis had two new cases of COVID-19 (this would put St Kitts and Nevis below the level 1 low-risk benchmark of 3-6 new cases over the last 28 days).
• The new case trajectory has been stable for months because our borders are closed and will remain closed until October 2020, although nationals abroad have been returning home after gaining approval from the Government.
• St Kitts and Nevis’ healthcare capacity – we have an entire ward dedicated to COVID-19 at the JNF Hospital and our Medical Chief of Staff has reported that the number of ventilators per capita is high, and is, in fact, higher than many countries in the Western world
• Our public health infrastructure – the Ministry of Health has a comprehensive contact tracing program which is implemented as soon as a new case is suspected, our testing capacity is high with all those who require testing being offered it and this includes mandatory testing for all approved incoming travellers.  Additionally, every incoming passenger enters a mandatory 14-day quarantine in a Government facility that is monitored by healthcare professionals and law enforcement

Comparing the CDC’s own criteria with the data from St Kitts and Nevis, it is clear that the Level 3 alert misrepresents the situation in St Kitts and Nevis, and we would encourage the CDC to correct this.

It is important to note that the UK Government has listed St Kitts and Nevis as one of the countries that is exempt from the Foreign and Commonwealth Office’s advice against all non-essential international travel based on their determination of the low COVID-19 risk in St Kitts and Nevis.

Who is the CDC?

The Centers for Disease Control and Prevention (CDC) is America’s leading public health organisation. They fall under the Department of Health and Human Services and their aim is to:

 “Protect America from health, safety and security threats, both foreign and in the U.S. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same.”

They are very influential not only in the United States but across the globe which means that when they issue a statement, it is viewed with a high level of credibility and this influences the public’s behaviour. Therefore, the CDC has a responsibility to provide accurate evidence-based information, and we believe this alert fails to do this.

Why Is It Important to Correct the CDC?

We believe it is important to correct the CDC because of the implications of the Level 3 alert. Firstly, it is false and misrepresents the risk of COVID-19 in St Kitts and Nevis.  Secondly, this alert comes with a recommendation that travellers should avoid non-essential travel to St Kitts and Nevis, this advice is detrimental to the economic recovery of St Kitts and Nevis.

The borders of St Kitts and Nevis have been closed since 25^th March 2020. Closing the borders was an extremely hard decision for the Government as tourism is one of the major industries in the Federation.

Since the closure of the borders, thousands of residents whose livelihoods depend on the tourism industry have faced job losses and it has been an exceedingly difficult five months.

The Government, health officials and the National Emergency Operating Centre has been carefully planning the re-opening of the borders and this is scheduled to take place in October 2020. The re-opening of the borders is expected to give the economy a much-needed boost and help those in the tourism industry get back on their feet. The CDC’s Level 3 alert may have unnecessarily hindered those plans by deterring travellers and this will put the recovery of St Kitts and Nevis’s economy at risk and affect the livelihood of thousands of citizens.

We believe that it is also very important to correct the CDC’s alert because this represents a long history of countries like America and the UK, continuing to discredit countries in the Caribbean and Africa.

For too long America, the UK and others have perpetuated a negative and condescending narrative of Black countries, insinuating that we are ill-equipped to lead our countries.

When we look at the response to COVD-19, many Caribbean countries including St Kitts and Nevis, have had very low rates of the disease, and this is not by some stroke of luck. Leaders in St Kitts and Nevis listened to the evidence provided by WHO, PAHO, CARPHA and local medical experts and took appropriate action. They developed an evidence-based strategy which included early border closures, and a host of non-pharmaceutical measures to control and contain COVID-19.

Soon after St Kitts and Nevis’ first case was confirmed at the end of March, all schools and non-essential businesses were closed, and a State of Emergency was introduced which led to a series of week-long 24-hour curfews and partial curfew days.  During this time, the Government, churches and local charities provided food and support to the vulnerable, a COVID-19 Emergency Relief Fund was established,  moratoriums on utility bill payments were announced, there were official daily COVID-19 briefings and a 24-hour COVID-19 hotline was introduced.

The restrictions on the public were slowly lifted as St Kitts and Nevis became COVID-19 free and businesses and other organisations were only allowed to open after being inspected and found to be compliant with the Government’s COVID-19 guidelines.

Furthermore, the wearing of masks is mandatory in public spaces, social activities are restricted, hand sanitisation is a requirement in all public buildings, the public has been encouraged to wash their hands thoroughly and frequently with soap and water and to practice physical distancing.

All of these measures have been effective and reduced the transmission of COVID-19 in St Kitts and Nevis.

St Kitts and Nevis’ approach to COVID-19 has been far superior to America’s approach which has been plagued by false information, denial of the seriousness of the disease, inequities, the inability of States to implement an evidence-based strategy, a lack of contact tracing, a lack of ventilators and a lack of willingness by the public to adhere to basic prevention measures.

The Caribbean has responded responsibly and effectively to COVID-19 and this is not an isolated incident. The Caribbean has many public health achievements. Looking specifically at St Kitts and Nevis, some of its key public health achievements include:

• The elimination of mother-to-child transmission of HIV and syphilis, receiving certification from WHO
• Mounting effective responses to the Zika, Dengue and Chikungunya outbreaks
• Increasing life expectancy
• Low maternal mortality
• A reduction in the number of deaths due to communicable disease

Conclusion

St Kitts and Nevis has been able to control the first wave of the Coronavirus and the reality is that currently, a person’s risk of contracting COVID-19 in St Kitts and Nevis is low and travellers to St Kitts and Nevis pose a greater risk to residents than residents do to travellers.

We appeal to the CDC to amend the risk level for St Kitts and Nevis to more accurately reflect the risk posed to those who would seek to visit St Kitts and Nevis once the borders open in October.

We have written to the CDC and encourage others to do so too.

******
Header Photo by Brian McGowan on Unsplash

Today’s blog post comes from Mariana Ndrio. Mariana is a second-year medical student at the University of Medicine & Health Sciences (UMHS) in St. Kitts and is currently serving as the President of the American Medical Student Association (AMSA) on campus.

Mariana has recently started volunteering with us as a research assistant and is supporting us as we conduct our fibroids qualitative study. She is also creating a fibroids and COVID-19 infographic which will be published shortly.  

Today, Mariana discusses the challenges that fibroids patients may be experiencing during this COVID-19 pandemic and shares some evidence-based self-care and stress management tips to help women with fibroids manage during this difficult period.

As the COVID-19 pandemic continues to prompt stressful changes to our daily routine and lifestyle, health-related worries regarding ourselves and loved ones have undoubtedly intensified. While the growing uncertainties stemming from financial difficulties and social isolation impact the health and personal decision-making of everyone across the globe, women suffering from uterine fibroids are facing unprecedented challenges in their attempts to preserve their mental and physical wellbeing.

Uterine fibroids are the most common benign tumours among women. While some cases of fibroids are accompanied by no side effects, other cases contain patterns of heavy menstrual bleeding, long and irregular periods, pelvic pressure and pain, constipation, frequent urination, and in rare occasions, infertility.

Treatment for fibroids can range from no treatment at all to surgery, depending on the severity of symptoms. Aside from apparent physical symptoms, the psychological impact of fibroids should not be disregarded. In a 2013 national survey of 968 women suffering from fibroids, 79% of the surveyed women expressed fear that their fibroids will grow or experience further health complications. According to a 2014 study assessing the emotional impact of fibroids half of the participating women reported feeling helpless and that they had no control over their fibroids, because of the difficulty managing and predicting the heavy menstrual flow.

Black women are 3 times more likely to become diagnosed with fibroids than white women, just as they are more likely to develop fibroids at a younger age; moreover, their fibroid size, frequency, and symptom severity are much greater.

As a medical student that remains generally impressed by the increasing amount of existing medical and scientific knowledge, researching gynaecological diseases such as fibroids have led me to a stark realization: that despite the high prevalence of uterine fibroids among women, not enough high-quality data is available to formulate evidence-based guidelines that address patients’ needs adequately. This points to a larger, unforgiving gap in medical knowledge pertaining to common diseases affecting women, and when combined with the gap in medical knowledge regarding COVID-19, a mixture of increased emotional stress and confusion is to follow. Such stress can hinder overall physical health and may exacerbate fibroid symptoms by influencing cycle length, vaginal bleeding patterns, and painful periods. If you are feeling uncertain or anxious, know that you are not alone; your worries and feelings are valid.

For that matter, we compiled some scientifically-backed tips that could be helpful in restoring a sense of control and ease in these difficult and unprecedented times.

First, don’t hesitate to reach out.

While staying home and self-isolating is the best way to stay protected from COVID-19 and prevent the spread of the virus, this should not halt or compromise access to necessary medical care for women suffering from fibroids.

If you need to see a healthcare provider for a gynaecological reason, reach out to your medical provider and try to see if they are able to set up a virtual appointment or address non-urgent concerns over the phone (such as prescription refills). 

While it is true that a lot of non-urgent appointments and elective surgeries are cancelled, many medical professionals and medical facilities are encouraged to use and have already embraced telehealth services which allow long-distance patient and clinician care via remote and virtual appointments, intervention, education, and monitoring. Telehealth services vary based on your location and medical provider. But even if you are having difficulties accessing gynaecological telehealth services locally, you might be able to reach out to service providers in other countries such as the U.K, U.S, or Canada. For example, USA Fibroid Centers provide virtual appointments you can schedule online. Women to Women OB GYN Care, located in Florida, states in their website that they welcome appointments from women internationally and the Caribbean. The Pan American Health Organization (PAHO) has also attempted to establish or expand telehealth services in a lot of Caribbean countries.

Keep up to date with your prescribed medications.

Keeping up to date with your prescribed medications can be confusing during a pandemic. You might feel like your regular access to your medical provider or pharmacy is compromised, you might worry that your current medications might be making you vulnerable to the COVID-19 or you might be feeling uncertain regarding the continuation of your current prescribed medications or supplements.

Nonetheless, it is important that you continue taking your prescribed medications and/or supplements unless otherwise advised by your physician.  If you are receiving preoperative therapy (Zoladex, Lupron, etc.) but your surgery is cancelled, ask your physician regarding the course of your current prescribed therapy. If you have been prescribed a drug called Esmya (Ulipristal Acetate), you must consult with your physician regarding its discontinuation; as of 2020, Esmya’s license has been suspended due to the risk of serious liver injury. As mentioned previously, do not hesitate to discuss any concerns you might have regarding your current medications and supplements with your medical provider.

Plan ahead.

Studies show that women with fibroids might present heavier, prolonged bleeding and frequent, irregular periods. While everyone during a pandemic is worrying and trying to secure produce and disinfecting supplies, women suffering from fibroids have to also think about stocking up on female hygiene products. Especially, since frequent trips to the stores must be limited due to social distancing/quarantine rules.

Ensure that you have enough gynaecological hygiene products at home, to eliminate frequent trips to the store and avoid exposure to the virus. This by no means should be considered as the green light to go into a buying frenzy. Try to remain conscientious of the needs of others.

If buying hygiene products in bulk is not an option due to financial difficulty or store availability, reach out to local non-governmental organizations (NGOs) or philanthropic entities, that might be willing to donate hygiene products such as the Days for Girls International Organization or even by reaching out directly to product manufacturers. Local grassroots organizations or associations in your region might also be able to donate hygiene items. Moreover, the governmental departments of public health or genders affairs might be willing to assist women in need of hygiene products.

This pandemic could also be a good time to consider reusable, more economical and environmentally friendly menstruation products such as washable pads, menstruation caps, or absorbent underwear.  Check Days for Girls .org and learn how to make sanitary washable period pads during the COVD-19 pandemic, diligently following sanitary safety precautions.

Maintain healthy eating habits. 

Research has shown that following a healthy balanced diet, filled with fruits and vegetables, could lower the risk of developing fibroids and may help to alleviate symptoms.

While access to your usual healthy foods might be compromised at the moment, try to make healthy dietary choices while in quarantine. More specifically, dieticians recommend an increase in the consumption of cruciferous vegetables such as cabbage, broccoli, and kale. This category of food contains a phytochemical called indole-3-carbinol which recent research has suggested may prevent the cellular proliferation of fibroids and consequently prevent exacerbation of fibroid symptoms.

For many years, there has been a significant amount of scientific evidence that vitamin D may inhibit fibroid growth. Get your serum vitamin D levels tested and supplement (with medical supervision) as needed to correct a deficiency. A few recently published studies assessing the role of vitamin D against COVID-19, suggested that there is a possible link between the two and that vitamin D can have a protective effect against COVID-19.

Stay hydrated by consuming adequate amounts of water during the day and eliminate alcohol and caffeine. Researchers are advising women to avoid alcohol and caffeine because these substances are metabolized by the liver adding more stress on it and making it work less effectively at metabolizing oestrogen in the body.  Additionally, amidst the COVD-19 pandemic, the World Health Organization (WHO) urged the public to reduce alcohol consumption because alcohol compromises the body’s immune system and increases the risk of adverse health outcomes, making people more vulnerable to COVID-19. In other words, by cutting out alcoholic beverages, you are protecting yourself from adverse outcomes from both the COVID-19 and fibroids.

In addition, researchers believe that endocrine-disrupting chemicals (EDCs) which mimic oestrogen activity, may fuel fibroid growth. Examples include processed foods which contain various oestrogen-like preservatives; bisphenol A in water bottles, canned foods and plastic containers; various pesticides, herbicides, insecticides; and additive hormones and steroids used in meats and dairy products.

Try to choose organic, locally grown and in-season foods that are hormone and pesticide-free. Attentively wash any produce and peel fruits and vegetables. Reduce the use of plastics whenever possible and avoid reusing plastic water bottles or microwave food in plastic containers.

Stay active.

Research shows that a higher BMI – body mass index – is linked to the development of fibroids. By exercising you can reduce your BMI and prevent the fibroids’ growth. It may also help alleviate symptoms caused by fibroids. At the same time, exercise improves mental health by reducing anxiety, depression, and negative mood and by improving self-esteem.

Continue performing simple or recreational household chores and find an indoor workout routine such as yoga or aerobic exercises that you can perform at home while keeping up with the rules of quarantine. Choose what works best for you, based on your physical fitness and medical advice.

Be gentle to yourself—your body & your mind

On days that you are feeling pain and other fibroid symptoms, rest up and give your body time to heal. Try to soothe cramps by applying heat and wear comfortable clothes.

It’s okay to spend a whole day in bed recovering. Be gentle with yourself and do not undermine what your body is trying to tell you.

We live in a society where time and productivity are precious and synonyms for money and self-worth. Yet, nothing is more precious than your physical and emotional well-being. Do not feel guilty for taking some time to rest and recover.

Although self-care looks different for everyone and should be based on your personal needs and situation, there are a few suggestions that could work for you and help you boost your mental well-being:

• Try to meditate and practice mindfulness. You can find a lot of free guided meditations online or on YouTube.
• Monitor your thoughts and feelings in a journal.
• Practice good sleep hygiene. Maintain a sufficient sleep schedule, stay away from electronic devices while in bed, and start a regular bedtime routine—such as drinking a soothing tea, taking a warm bath or shower, reading, etc.
• Limit the amount of media you ingest daily.
• If you live alone reach out to family and friends via phone or video. If you live with family, roommates, or a partner use this time to connect and nurture your relationships.

And remember, during these confusing and unprecedented times and while you are feeling that this pandemic is affecting you, in particular, a bit harder than the rest, there is always a community of women who are feeling exactly like you—you are not alone.

Sources

1. Mayo Clinic website: “Uterine Fibroids.” – http://www.mayoclinic.com/health/uterine-fibroids/DS00078.
2. Seminars in reproductive medicine: “Uterine Fibroids: Burden and Unmet Medical Need.” – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6193285/
3. CARE About Fibroids: “Uterine Fibroids: The Emotional, Physical, and Economic Toll.” – http://www.careaboutfibroids.org/toll-of-fibroids.html
4. The BMJ, British Medical Journal Publishing Group:  “Uterine Fibroid Drug Is Recalled after Case of Liver Failure Requiring Transplant Prompts EU Review.” www.bmj.com/content/368/bmj.m1112.
5. American Journal of Clinical Nutrition: “Dietary glycemic index and load in relation to risk of uterine leiomyomata in the Black Women’s Health Study.” – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2854903/
6. Journal of Obstetrics and Gynaecology: “Vegetarian diet and reduced uterine fibroids risk: A case-control study in Nanjing, China.” https://www.ncbi.nlm.nih.gov/pubmed/26458740
7. Reproductive Biomedicine Online Journal: “Quercetin and indole-3-carbinol inhibit extracellular matrix expression in human primary uterine leiomyoma cells” – https://www.sciencedirect.com/science/article/abs/pii/S1472648320300249
8. Fertility and Sterility Journal:  “Endocrine-disrupting chemicals and uterine fibroids.”- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5051569/
9. Healthline Magazine: “How Alcohol Can Affect your Immune System.”- https://www.healthline.com/health-news/can-alcohol-hurt-your-immune-system-during-covid-19-outbreak
10. The Elusive Magical Solution: The Relationship between Vitamin D and Fibroids- https://scholars.direct/Articles/gynecology-and-obstetrics/ago-3-008.php?jid=gynecology-and-obstetrics
11. The role of Vitamin D in the prevention of Coronavirus Disease 2019 infection and mortality- (https://www.researchsquare.com/article/rs-21211/v1)
12. American Journal of Epidemiology: “Association of Physical Activity with Development of Uterine Leiomyoma.”                – https://academic.oup.com/aje/article/165/2/157/97971
13. Mayo Clinic: “ COVID-19 and Your Mental Health”- https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/mental-health-covid-19/art-20482731
14. Lake Health and Wellbeing: “Fibroids and your Mental Health.”- https://lakehealthandwellbeing.com/newsite/wp-content/uploads/2019/05/FibroidsANDEmotionalWellbeingVersion2.pdf

To contain the spread of COVID-19, the government of St Kitts and Nevis declared a State of Emergency on 28^th March 2020. Since that declaration, we’ve had a combination on 24-hour and partial curfew days and our borders have been closed.  This quick action by the government has been effective and the number of COVID-19 cases has remained fairly low. We have had 15 cases, 8 of those cases have recovered and we haven’t had a new case in over 10 days.

Whilst this is all good news in terms of the pandemic, the closure of our borders and the lock-downs have been devastating to our economy which is heavily dependent on tourism. This has led to many businesses shutting their doors, school closures, and people being laid-off or placed on reduced hours. This has created a lot of anxiety and uncertainty about the future which the government has tried to address through a number of support programmes such as the COVID-19 Relief Fund, the expansion of the Poverty Alleviation Programme, moratoriums on utility bill payments, a range of social services to support the vulnerable and psychological support to address the mental health impact of the pandemic.

One service, which we have been delighted to be assisting with is the COVID-19 Helpline. This is a service established by the Ministry of Health and the National Emergency Management Agency  (NEMA) to give the public someone to easily reach out to if they have a COVID-19 related question, need support during this time and are concerned that they may have COVID-19 symptoms. When the public calls 311, their concerns are discussed with a friendly helpline operator (like us 😊) and then they are signposted to the relevant government department or an NGO for their issue to be addressed.

It has been very fulfilling volunteering with the helpline and being able to help those who are experiencing a number of challenges during this time. We’re just so happy that the support available in the Federation is comprehensive and holistic. So far, there has been a programme to address all the concerns we have had from callers and many have ended the call feeling happier and more at peace.

If you are based in St Kitts and Nevis and have a question about COVID-19, curfew timings, the COVID-19 relief fund, then please don’t’ hesitate to call 311 (it’s a free call). To find out more about the helpline, you can view the video below and for general information about COVID-19 in St Kitts and Nevis, you can visit https://www.covid19.gov.kn/