Introduction

In this chapter, the impact of the pandemic on health in Mexico, in particular, in the state of Querétaro, is presented. Epidemiological trends regarding incidence, prevalence, and mortality are examined. And health policies are reviewed.

On December 31, 2019, Wuhan, China, reported a conglomerate of cases of acute respiratory syndrome of unknown origin. Some of these cases were vendors in the Wuhan seafood market which was closed on January 1, 2020 [1]. On January 7, 2021, the Chinese authorities reported that a new coronavirus (nCoV) had been identified. On January 30, the World Health Organization (WHO) declared that the outbreak of 2019-nCoV was a public health emergency of international concern [2].

The first confirmed case of COVID-19 was detected on February 27, 2020, in Mexico City. The patient was a Mexican who had traveled to Italy; he had mild symptoms [3]. On March 11, 2020, the WHO declared COVID-19 a pandemic. A few days later on March 18, the first death from COVID-19 was registered in Mexico. Mexico featured among the countries with the highest fatality rates. It ranked second in terms of the fatality rate (7.6 deaths per 100 infections). Peru ranked first [4].

According to official data from the National Epidemiological Surveillance System (SS), close to 4.0 million confirmed cases and 306,062 deaths from COVID-19 have been reported in Mexico. The incidence rate of COVID-19 is 2,9860 per 100,000 inhabitants. Figure 1 shows Mexico´s epidemic curve with the number of confirmed cases and deaths according to SS. The epidemic curve presents two infection peaks. The first one was in mid-January 2021. The second, in early August 2021, exceeded the first peak in the number of cases. Sex disaggregated data shows that there is a gender difference worldwide [5]. In Mexico, at the beginning, the distribution by sex in confirmed cases showed a higher prevalence in men (58%). Currently, the number of confirmed cases is similar in men and women (49% vs. 51%) but men have higher rates of hospitalization, intensive care admissions, and deaths (Fig. 2). The median age of COVID-19 cases in Mexico is 44 years.

Fig. 1
A multiple-line graph plots the daily confirmed COVID-19 cases and deaths in Mexico. The number of cases peaks at 20000 and 25000 and the number of deaths slightly peaks in January 2021 and then almost remains constant.

Source Authors’ elaborated based on the General Directorate of Epidemiology (GDE) database

Daily confirmed COVID-19 cases and deaths in Mexico.

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Fig. 2
A stacked bar graph depicts the prevalence percentage for COVID cases, deaths, intensive care admissions, and hospitalizations for men and women. The proportion of deaths and intensive care admissions is the highest for men equal to 65% approximately.

Source Authors’ elaborated based on the General Directorate of Epidemiology (GDE) database

Distribution of COVID-19 cases and deaths by gender in Mexico.

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There were 395,000 accumulated deaths by October 2021 (Fig. 1). Mortality was higher in people with pre-existing comorbidities. Comorbidities associated with higher mortality were hypertension, diabetes, obesity, and smoking [6]. Until November 12, 2021, 38.2% of the deaths were reported in women and 61.7% in men (Fig. 2). A study of COVID-19 in eight countries in Latin America (Brazil, Peru, Mexico, Argentina, Colombia, Venezuela, Ecuador, and Bolivia) showed that hypertension (12.1%) was the most common comorbidity followed by diabetes (8.3%), and obesity (4.5%) [7].

According to the National Survey on Health and Nutrition (ENSANUT), Mexico has a high prevalence of obesity and diabetes. The prevalence of overweight and obesity in Mexico has increased in recent years. From 1980 to date, the prevalence of these diseases tripled. Currently, the weight of over 70.0% of the adult population in Mexico is above the recommended level [8]. Excess weight is one of the main risk factors in the development of chronic non-communicable diseases such as diabetes mellitus, hypertension, and cardiovascular diseases. And these diseases increase the severity of COVID-19.

With a population of 2,038,372, Querétaro ranks 22 in the number of inhabitants among the states of the Federation. Queretaro represents 0.6% of the territorial extension of the Mexican Republic (Fig. 3); 175,000 of its inhabitants are over 60 years of age and so are at risk of contracting COVID-19 [9]. Regarding the Human Development Index (HDI) and health, the state of Querétaro occupies the seventh and twelfth places, respectively, according to the ranking of the United Nations Development Programme (UNDP, 2015).

Fig. 3
A pie chart and a map highlight the population distribution of the state of Queretaro depicting a 0.6% population distribution.

Source Instituto Nacional de Estadística y Geografía (INEGI), 2011

Population distribution of the state of Querétaro in relation to the national territory.

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The state of Querétaro is organized into four health jurisdictions (Queretaro, San Juan del Rio, Cadereyta, and Jalpan). There are more than 250 public health institutions in Queretaro and San Juan del Rio. There are five second level hospitals (2 in Queretaro, 1 in San Juan del Rio, 1 in Cadereyta, and 1 in Jalpan), and approximately 200 first level healthcare centers [10]. In addition, healthcare is provided by a voluntary public program Seguro Popular which is financed by the Federal Government and private insurance (IMSS, ISSSTE). This program covers about 85% of the Mexican population [11].

The main causes of death in the state are non-communicable diseases including ischemic heart disease, diabetes mellitus, and cancer. Influenza and pneumonia are among the top 10 causes of death in the state [12]. Excessive weight is linked to several health problems [13]. Epidemiological studies suggest that obesity could have an adverse impact on COVID-19, especially in severe cases, and could increase mortality [14]. In Mexico, obesity is the strongest predictor of COVID-19 followed by diabetes and hypertension [15].

On March 11, 2020, the first confirmed case of COVID-19 was reported in Queretaro [16]. By October 30, 2021, there were more than 90,000 confirmed cases. The highest peak was in January with a second peak in August (Fig. 4). The incidence of COVID-19 was similar in women (45%) and men (55%). Although not considered a risk group, there were more confirmed cases in persons 25–34 years of age (27%) [17].

Fig. 4
A multiple-line graph depicts the confirmed COVID-19 cases and deaths in Queretaro. The number of cases peaks up to 810 approximately in December 2020 and the deaths remain constant after a slight peak in January 2021.

Source Authors’ elaborated based on the General Directorate of Epidemiology (GDE) database

Daily confirmed COVID-19 cases and deaths in Queretaro.

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Higher mortality was reported in men than in women, 63% and 37%, respectively. Mortality was highest in persons over 60 years (57%). Comorbidities associated with deaths from COVID (n = 5,929) were hypertension (40%), diabetes (28%), obesity (21%), and chronic kidney disease (6%) [18].

Queretaro showed the lowest case fatality rate for COVID-19 in Mexico (Fig. 5). Despite having a larger number of confirmed cases in the capital of Queretaro, the fatality rate was two percentage points below the national average (Table 1).

Fig. 5
A bar graph depicts the percentage fatality ratio in Mexico. It is the highest for Baja California equal to 14.0 and decreases further.

Source Authors’ elaborated based on the General Directorate of Epidemiology (GDE) database

Case fatality ratio in Mexico.

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According to the State Development Plan 2016–2020, Queretaro did not have the number of beds recommended by the World Health Organization (1 bed per 1,000 population) [19]. To avoid overburdening the healthcare system, hospitalization was reserved for severely ill patients. In Queretaro, 12% of confirmed cases required hospitalization which was three percentage points below the national average [17].

Table 1 Confirmed cases and deaths in Queretaro
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Health Policies in Mexico and Querétaro

When the first death was registered in Mexico, the first, second, and third level Epidemiological/Hospital Surveillance Units (UVEH) in the country, members of the National Network of Public Health Laboratories, and staff of the National Health System issued a report through the National Committee for Epidemiological Surveillance (CONAVE) wherein parameters were established to identify suspected and confirmed cases of COVID-19. A suspected case was a person of any age who presented acute, mild, or severe respiratory disease and who had any of the following antecedents up to 14 days before the onset of symptoms: (1) had been in contact with a confirmed case or had been under investigation for COVID-19 and (2) had made a trip or stayed in countries with local transmission of COVID-19. A confirmed case was a person who met the operational definition of a suspected case and had a confirmed diagnosis by the National Institute for Epidemiological Diagnosis and Reference (InDRE) [20].

On March 23, 2020, 367 cases and four deaths from COVID-19 were confirmed in Mexico: two in Mexico City, one in Durango and one in Jalisco. The Federal Government closed all schools. A program called ‘Sana Distancia’ was launched by the Mexican Ministry of Health. Recommendations were made regarding basic prevention measures such as frequent hand washing, respiratory etiquette, greeting from a distance, and staying home if symptoms were present. There was a temporary suspension of non-essential activities. There was a rescheduling of mass events. And measures to protect and care for the elderly were implemented. To emphasize the importance of physical distance, a communication campaign was designed using cartoons that featured a heroine called ‘Susana Distancia’ [21].

On March 30, 2020, the General Health Council declared COVID-19 a health emergency, and all non-essential activities were suspended till April 30, 2020, to mitigate the spread of COVID-19 in the community and to reduce the burden of disease [22]. Although there was a 44% increase in the number of cases [2,527 new confirmed cases], in order to reactivate economic and social activities, on May 13, 2020, the plan to reopen non-essential activities called ‘New normality’ was announced [23]. An epidemiological traffic light was used for monitoring. The traffic light was defined weekly according to the risk by region. Its color indicated what activities could be carried out. The regions identified with the red color represented the maximum epidemiological risk. Orange represented a high epidemiological risk. The colors yellow and green represented intermediate and low epidemiological risk, respectively. This traffic light system began on June 1, 2020, at the state level [24]. In regions identified with red color, only essential activities were allowed. In regions identified with the orange color, in addition to essential activities, non-essential activities could be reactivated although they were to be carried out at a capacity of 30% and with strict safe distance measures. In regions identified with the yellow and green colors, essential and non-essential economic activities could be conducted at full capacity as long as measures were taken to protect the health of workers [25].

On July 24, 2020, the Ministry of Health of the Government of Mexico, through the Institute of Health for Wellbeing (INSABI) and the Undersecretariat for Prevention and Health Promotion (SPPS), in collaboration with the Pan American Health Organization (PAHO), Mexico and the Secretariat of Welfare designed a strategy for promotion, prevention, care, and mitigation of COVID-19 and for monitoring essential public health actions at the community and the first levels of care within the framework of primary healthcare (PHC). The aim was to strengthen the response of the local health system to the pandemic. The following three action groups with specific action objectives were established [26]:

  • (1) The Community Health Promotion Brigade: Its function was to request information from the Director of the Health Unit about people with risk factors for COVID, generate data updates, apply general questionnaires and notify, provide information to reduce the risk of contagion, identify persons within the patient's home for follow-up, strengthen health promotion actions, and develop a directory of public health officials according to the health problem and characteristics of the identified population.

  • (2) The Specialized Brigades: Their function was to follow-up suspected cases that belonged to the risk groups described above. Daily follow-up was conducted by telephone or in-person with people in the community with ARI (acute respiratory infection). The status of the identified persons with any health problems was evaluated. Patients suspected of COVID-19 were monitored. Blood pressure of all adults 20 years of age and older was taken. Cases that required care in remote consultation units (UCID) were identified. Patients considered in risk groups were clinically evaluated to determine if they should be isolated. Preventive actions were implemented. A ‘brief mental health screening’ questionnaire was completed. Patients were provided information on self-care. They were also provided First Psychological Aid if needed and were given timely information on specialized mental health services. Pregnant women were also reviewed.

  • (3) The Clinical Care Team: Its function was to evaluate and treat patients referred by the brigades, provide clear information on the evolution of the disease and its consequences, communicate with the isolated persons, provide psycho-education, provide information on the lines of support, provide psychological support, and refer in a timely manner to Specialized Mental Health Services.

On March 11, 2020, the Secretary of Health of the State of Querétaro (SESEQ) confirmed the first case in the city. This was a 43-year-old man from Spain who was isolated at his home. He was kept under medical observation. His situation was stable. Coordination with the federal authorities was maintained in order to provide timely follow-up using protocols and guidelines and to provide adequate care. The staff of the Ministry of Health had the necessary supplies and were trained to address this situation [27].

The public was exhorted to participate in containing the disease by implementing preventive measures and visiting the doctor when symptoms of an acute respiratory disease appeared (fever, cough, respiratory distress or chest pain). Two operational criteria had to be present: (1) the patient had been contacted 14 days prior to the appearance of symptoms with a person confirmed with COVID-19 and (2) the patient had traveled to a city that had community transmission [28].

Preventive measures included: frequent hand washing with soap and water or 70% alcohol gel solution, covering the nose and mouth with a disposable tissue when sneezing or coughing or using the internal angle of the arm, avoiding spitting, but if necessary, spitting in a disposable tissue which would be put in a plastic bag and thrown away, cleaning and disinfecting surfaces and objects commonly used at home and in schools, offices, closed places, transport, meeting centers, etc. Avoiding touching the face, especially the nose, mouth, and eyes, avoiding direct contact with people with symptoms of cold or flu, visiting the doctor when there were respiratory ailments (fever greater than 38 degrees, headache, sore throat, runny nose, etc.), avoiding self-medication, staying at home when there were respiratory symptoms, avoiding going to crowded places, keeping workspaces and housing units well ventilated, and drinking plenty of fluids. Finally, the use of face masks was recommended for patients with respiratory symptoms and people were urged to follow information provided through institutional channels [29].

The SESEQ included within its website, a COVID section on the Health Risks Directorate section and incorporated a tab called COVID-19 legislation in documents that were made available to citizens. At least 15 agreements were issued during the COVID-19 pandemic [27]. In these agreements, general recommendations were made to undertake health security measures. These were shown to the general population and to the health personnel. Other agreements focused on the suspension of economic, productive, and social activities.

During the emergency period, a Call Center for Medical and Emotional Attention was set up to inform people about physical and psychological symptoms related to COVID-19, resolve their doubts, and make appropriate referrals [30].

The Mexican Institute of Social Security (IMSS) implemented a hospital reconversion strategy in eight entities to address bed requirements which meant increasing the number of beds by 39% to reach 6,116 by the end of January 2021 in the states of Querétaro, Hidalgo, Puebla, Morelos, Guanajuato, Nuevo León, Jalisco, and Michoacán. In Querétaro, there were 380 beds and reconversion meant adding 104 to reach a total of 484 beds which was the number needed [31]. The Querétaro General Hospital shelter and the Children's and Women's Specialties Hospital were upgraded to provide medical care to COVID-19 cases that needed hospitalization.

In the second half of April 2020, the Congress Center became a Medical and Isolation Unit (UMA) to serve patients who were positive for COVID-19 but did not require hospitalization. UMA served 250 patients—125 women and 125 men. This number was later increased to 700 patients [32].

On November 28, 2020, the Secretariat of Health of the Executive Power of the State of Querétaro through the official gazette, envisioned future scenarios. In accordance with the criteria of the Technical Committee for Attention to COVID-19 and the Specialized Multisectorial Group for Epidemiological Surveillance of COVID-19, three scenarios were envisioned: Scenario A remission: hospital occupancy at 39%. Scenario B prevention: hospital occupancy between 40 and 70%. And Scenario C containment: hospital occupancy greater than 70% [33].

With a total of 30,215 accumulated cases and 2,049 deaths, on December 19, 2020, Scenario C was established in the State of Querétaro [34]. The positivity index was close to 38% and the increase in hospital occupancy in the absolute number of beds occupied by patients without the use of assisted ventilation was 48%. The percentage of patients with ventilator support was 49%. A total of 471 hospitalized patients reached 60% hospital occupancy [35]. According to the number of active cases of SARS-CoV-2 virus infection, the positivity index, and the increase in hospital occupancy, Scenario C remained in force until February 14, 2021. By then, the total number of accumulated cases was 51,162 and there were 3,371 deaths [36].

On February 12, 2021, Scenario B was established in the State of Querétaro. Sanitary security measures were implemented and remained in force until April 22, 2021. On February 10, 2021, hospital occupancy was reduced by 12% with 37% occupancy of beds with ventilator support and 50% occupancy of beds without ventilator support [37].

Local Strategies to Respond to COVID-19

The COVID-19 pandemic dramatically changed health systems around the world. It changed the way in which outpatient care was delivered to decrease the risk of transmitting the virus to patients and to healthcare workers. Vaccines and treatments were also developed [38]. On the other hand, the lockdown period imposed drastic changes in the behaviors and lifestyles of the people in terms of physical activity and quality of diet both of which are known to play an important role in disease management [39, 40].

The management of large numbers of COVID-19 patients over a short period of time disrupted the healthcare system. High demand for hospitalization beds overwhelmed the healthcare system [41]. As a response to the pandemic, the Mexican government promoted several strategies like physical distancing to limit the spread of COVID-19. However, it is important to note that very few strategies were implemented to ensure the continuity of essential health services [42]. The public and private health sectors repurposed multiple hospitals, reallocated health personnel, and diverted medical equipment and supplies to treat COVID-19 patients. There has been a lack of investment in the health sector in Mexico historically. Health expenditure in Mexico is only 5.5% of the Gross Domestic Product (GDP) [43].

Through the University Health System, the Autonomous University of Queretaro organized an integrative care clinic ‘Clinica de Atencion Integral COVID’ dedicated to providing COVID-19 services and diagnosing and monitoring patients at home. The goal of this clinical service was to provide multidisciplinary assessment and treatment by a system that included virtual phone-based assessment and clinical home monitoring. The Clinica de Atencion Integral COVID offered a multidisciplinary care model in which physicians, nutritionists, physical therapists, pharmacological chemists, psychologists, and other staff members played a role in delivering comprehensive care. A description of the activities in each of the clinic's care areas is provided below.

Detection Area

At the beginning of the pandemic, a group of scientists from the Autonomous University of Queretaro offered SARS-CoV-2 virus detection services to the people through the use of the university's own resources. Detection was carried out by means of a molecular screening test. More than 2,000 free tests were offered to the population at risk. It was found that approximately 80% of infected people did not have symptoms or had mild symptoms. This was an important finding because it made it possible to detect and isolate carriers to prevent the spread of the virus, particularly for those most susceptible.

Clinical Household Follow-Up Program

Carriers of SARS-CoV-2 were invited for clinical follow-up which included a symptoms questionnaire to be administered by telephone screening to find out if the patient was a candidate for follow-up at home. Only patients with low and medium risk were accepted into this program. Patients with high risk were referred to a specialized care service. A series of visits were made to the patient's home to record signs and symptoms such as temperature, oxygenation, an olfactory test, and an antibody test. The first home visit was made by medical personnel. In subsequent visits, a pharmacological chemist obtained a blood sample to measure antibodies and a nutritionist performed a nutritional assessment.

Nutrition plays an important role in the management of COVID-19 [44]. Undernutrition, micronutrient deficiencies, and overnutrition increase the risk of developing serious complications [45]. The aim of the nutritional assessment was to identify nutritional risk in COVID-19 patients and assess its association with disease outcomes. In the beginning, the assessments were focused on identifying the risks of undernutrition. Nutritional assessment was later modified to assess metabolic risk factors. In patients included in this program risk factors like hypertension (30%), obesity BMI > 30 (27%), and diabetes (10%) were also assessed.

Rehabilitation: Post-COVID-19 Program

COVID-19 resulted in several medical, social, and psychological consequences like multi-organ failure of the heart and kidneys and vascular damage [46]. Specific rehabilitation needs to be undertaken for post-COVID-19 patients to achieve respiratory improvement and functional and cognitive recovery, decrease disability, and improve the quality of life [47].

Persistent symptoms were present in patients who had recovered from COVID-19 in Mexico [48]. There was no rehabilitation clinic in the private or the public sector where comprehensive multidisciplinary services could be offered for the treatment sequelae of COVID-19. A multidisciplinary team participated to address cardio-pulmonary, nutritional, and psychological sequelae.

The assessment included a clinical history to obtain the patient’s sociodemographic data, data related to diabetes, cardiovascular risk factors, and other comorbidities. Information on smoking and alcohol consumption and dietary intake was obtained by using a food frequency questionnaire. A battery of tests were conducted including laboratory testing, testing for respiratory conditions, functional status, quality of life, psychiatric conditions, and nutritional status.

The goal of the nutrition service was to assess the nutritional sequelae of COVID-19 and then to give personalized advice to the patients. Body composition analyses were performed by bioimpedance with a Body Composition Analyzer mBCA 514/515 Seca GmbH & Co. KG, Hamburg. This breaks down weight into body compartments (muscle mass, body fat, and visceral fat). As would be expected, the principal nutritional risks found in patients post-COVID-19 were obesity, loss of muscle mass, and a decline in overall physical functioning. However, in our experience, after six weeks, muscle mass and nutritional status improved in these patients. It is important to note that medical and physiotherapists participated in the program.

The assessment also included circadian rhythmic features. It has been repeatedly acknowledged that the adequate functioning of the rhythmical system is essential for maintaining the homeostasis of an organism [49]. Studies focusing on the effects of lockdown as a result of the pandemic showed that human performance and health, especially quality and quantity of sleep [50], nutrition, and physical activity were affected [51]. A recent study shows that the complex pathogenesis of severe acute respiratory syndrome by SARS-CoV-2 infection is related to circadian disruption [52]. Thus, in considering the disturbances of the biological timing for nutritional assessment according to light–dark cycles, timing of food intake, light at night, nocturnal feeding, physical activity, jet lag, and shift work are of prime importance [53].

In conclusion, Mexico is among the countries that have the highest COVID-19 fatality rates. Efforts were made to expand hospital capacity. However, there were significant disruptions in the health services. The health system needs to resume essential services and should catch up on missed preventive care even as the COVID-19 crisis continues in Mexico. A comprehensive assessment is the key factor in the management of COVID-19 and in identifying specific clinical needs for comprehensive and individualized care.