Introduction

On March 11, 2020, the World Health Organization (WHO) declared the Coronovarirus Disease 2019 (COVID-19), caused by the infection with SARS-CoV2, a newly discovered coronavirus, a pandemic.¹ Since then, the rapid spread of the virus has affected many regions, including Latin America and the Caribbean (LAC), where, as of March 17, 2021, the number of confirmed cases reportedly exceeded 53 million.² In terms of confirmed COVID-19 cases, Brazil is the most affected country in the region, followed by Colombia, and Argentina.²

Although preventive strategies have been implemented, urgent attention to the health crisis derived from the COVID-19 outbreak is still required in LAC. Several research efforts have been carried out to achieve a clearer understanding of the disease, notably, through the accelerated growth in peer-reviewed and not peer-reviewed (preprints) articles.^3,4 For instance, articles addressing COVID-19 or topics related to it have been made freely available online to the general public,⁵ while the usual time required for them to be accepted and published in academic journals has decreased significantly, with some papers reportedly undergoing a one-day peer review and publication process.⁶ However, it is essential that emerging research prioritizes quality over quantity for the progress of medical practice in the context of the COVID-19 pandemic.

In this context, bibliometric analysis allows for a comprehensive evaluation of trends and progress in scientific production,⁷ thus helping researchers and policy makers to develop disease-related public health initiatives.⁸ Bibliometric studies focused on COVID-19 articles published to date have shown descriptive patterns of worldwide COVID-19 research output by mapping international collaboration, evaluating the citation performance of different documents, and ascertaining the relative contribution of different research approaches to the total body of evidence.⁹ Though these studies have been conducted mostly by authors with Chinese affiliations, they have been primarily focused on global results.¹⁰

Currently, Latin America has become the new epicenter of the pandemic,¹¹ as this region surpasses the number of deaths in the United States alone, with over 530 000 deaths attributed to infection with SARS-CoV-2.² Nevertheless, despite the severity of the scenario, there is scarce literature addressing the research strategies developed in LAC to face COVID-19. In this regard, there are several bibliometric studies conducted in the region during the pandemic,^12-14 but the present study broadens the bibliometric impact indicators provided and extends time interval analysis compared to these studies. A comprehensive evaluation of the current research production in LAC is essential to support the making of regional and national health policies, describe current and future research priorities, and plan interventions to tackle COVID-19 in the region.

Taking this into account, the objective of this paper was to quantify and assess the production of scientific publications about COVID-19 in 32 countries of LAC between January and July 2020.

Materials and methods

This is a cross-sectional study embedded in a bibliometric analysis. Research data were extracted from the PubMed, Scopus, and LILACS electronic databases. PubMed and Scopus have a high coverage of English-based journals, whereas LILACS includes local journals in LAC published mostly in Spanish and Portuguese.

Results

The search strategy yielded a total of 3 686 papers in Scopus/PubMed/LILACS databases published between January 1 to July 31,2020. Afterthe screening process (Figure 1), 1 122 duplicate articles were excluded, and an additional 1 273 articles failed to fulfill the inclusion criteria. As a result, 1 291 (35%) studies were selected for the final review and statistical analysis.

Source: Own elaboration.

Figure 1 Screening and selection process of the records according to the PRISMA (Preferred Reporting Items for Reviews and meta-analysis) flowchart.  

Original publications: overall trend, country-specific contribution, and impact

Regarding original research articles (n=236), most of them were published in Q1 journals (n=112; 47.46%), with most of these articles being classified as multiple collaborations (n=44; 39.28%). Brazil was the main producer of Q1 publications (n = 39; 34.82%) across the region, but also had the largest number of publications in non-indexed journals (n = 16; 66.67%). Figure 2 shows that among original publications, the most prevalent study design was the category "other" (53.81%), and the least common design was case-control (0.84%). Multiple collaboration produced more meta-analysis and cross-sectional publications compared to Brazil.

Source: Own elaboration.

Figure 2 Distribution of original publications by study design in LAC (n=236). The bars represent the distribution of study designs (ecologic, cross-sectional/prevalence/survey, case-control, cohort, randomized controlled trial, meta-analysis, other) among original studies in Latin America and the Caribbean region. The category "others" includes genomic, mathematical modelling, and laboratory studies.  

The focus of the different types of original articles (n=236) is summarized below:

Discussion

Opportunities to study COVID-19 and its various effects have increased dramatically during this unprecedented pandemic. Even though LAC is not a region known for producing a lot of research, it has made efforts to combat the pandemic, some of which are still ongoing. However, the first line of defense against a pandemic is information, which can only be obtained through research. The goal of the present study was to quantify and assess the output of LAC scientific literature specific to the COVID-19 crisis. The following were the main findings: (i) most articles in the region were non-original (81.6%), (ii) there was a lack of interventional studies among original articles, and (iii) epidemiology/surveillance was the main research focus (24.1%).

In many ways, the results obtained here greatly contribute to the current understanding of the production of COVID-19-related publications in LAC countries. First, we built upon previous bibliometric studies conducted in the region, which presented data until April and only included Latin American countries;^12-14 the present study provides data until July and included Caribbean countries in the search. Second, a subgroup analysis of only original articles was performed to quantify and ascertain better the contributions made in LAC of COVID-19-related publications. Thus, it was possible to describe the publication trend of these contributions by country, study design, research focus, and journal ranking, whereas previous bibliometric research on COVID-19-related publications in the region primarily focused on production variables.^12-14 For example, one analysis of COVID-19-related publications in LAC using several databases mostly provided general evidence by type and topic of local scientific production regarding COVID-19.¹³ In contrast, the present analysis provides a detailed overview of the COVID-19 publications conducted in the LAC region by categorizing them by study design and eight different research focuses. Hence, the topics that were not covered in said study were included here, such as health-care delivery and public policy issues.

The fact that scientific production in LAC decelerated during the month of July is alarming, considering that COVID-19-related mortality continues to rise in the region. This may be due to a delay in the indexing process of databases in relation to the date of search. Another possible reason could be the economic repercussions of the pandemic, particularly if research budgets have been cut to supplement institutions that have been providing aid during the crisis.¹⁷

To maintain a consistent flow of scientific output, LAC must once again adapt to perform research efficiently with limited resources. Several countries across the region have implemented policies to provide financial aid for conducting research on the pandemic. Brazil, for instance, has allocated more than 100 million dollars to conduct research focused on diagnosis and prevention of SARS-CoV2 infection.¹⁸ However, investment does not always translate into a direct increase in scientific output to combat COVID-19. Governments in LAC have displayed a lack of awareness by failing to recognize the importance of generating knowledge, which ultimately benefits all members of society.¹⁷ The current crisis is an important opportunity for regional stakeholders to support the implementation of appropriate public health decisions and initiatives leading to an overall rapid recovery of the region from the negative effects of the pandemic.¹⁹

It is worth noting that a high output of scientific literature does not necessarily mean that a country is producing quality research; thus, other factors need to be assessed.²⁰ The majority of articles in our study (40.59%) were published in a Q1 journal, which is associated with a higher journal quality and prestige. This percentage increased to 47.45% when original publications were assessed alone. Compared to our findings, Gregorio-Chaviano et al. found that Latin American publications about COVID-19 were published mostly in Q2 and Q3 journals (30.28%).¹⁴ One possible explanation for this finding is that this analysis used a search strategy that retrieved research published up until April 23, 2020, resulting in a smaller sample size compared to our study. Overall, LAC researchers preferred to publish in the journal Travel Medicine Infectious Disease (n=31), as described in another study,¹⁴ followed by Cadernos de Saúde Pública (n=26). Nevertheless, a bibliometric study by Gallegos et al. that analyzed 117 articles indexed until May 2020 in regional scientific databases found that Cadernos de Saúde Pública was the most prevalent journal,²¹ which is not surprising considering that Brazil is the country with the largest scientific production of the region, ranking tenth in terms of COVID-19 research production worldwide with a total of 249 articles based only on first author information, compared with 96 studies we found.²²

Original articles involving multiple collaborations are more likely to be published in a Q1 journal than those written by authors from a single country (39.28% vs. 34.82%, p-value <0.05), demonstrating that collaborative research between developed and developing countries brings together the necessary skills and brainpower to maximize research efforts.^23,24

In general, there are more non-original articles (81.6%) than original articles (18.3%) in the region. In the non-original articles category, 59.6% articles are commentaries, letters to the editor or editorials, similar to what has been reported in other parts of the world,^3,25 reflecting the rapid increase in scientific production at the beginning of the pandemic. One possible explanation for the increase in non-original articles could be that journals implemented a fast track for revisions of COVID-19-related articles, with a median time of acceptance of 2-6 days.⁵ Another reason why most research production from LAC at the time was non-original may be that, at the beginning of the pandemic, most of the disease burden fell on China and European countries (Spain and Italy), while LAC countries were preparing their healthcare systems to receive imported cases. Consequently, most of the COVID-19-related publications coming from LAC during the first trimester of 2020 reflected personal opinions on how containment efforts should be undertaken at the local, national, and regional levels.

In the present study, observational studies led the publication pattern in the region. Experiences such as Ebola in 2014 show that research on these topics is usually cross-sectional rather than longitudinal. This could be explained by the fact that health emergencies are alleviated faster with short-term benefit actions than with long-term observation.²⁶ However, the SARS-CoV-2 virus seems to behave differently than previous viruses such as MERS and SARS-CoV-1.²⁷ In 2003, the SARS epidemic was contained because most patients were symptomatic, and transmission from person to person was not as efficient as in the case of the SARS-CoV-2 virus.²⁸ Thus, COVID-19 continues to be a threat that requires both immediate and long-term attention.

During the study period, the production of studies in LAC with the quality of evidence required to support the formulation of health policies, such as cohorts, RCTs, and meta-analysis, is limited (2.97%, 2.12% and 6.36%, respectively). Unfortunately, despite a strong enrollment capacity, this is not the first time that LAC has struggled with clinical research.²⁹ One of the main reasons for this situation could be the lack of a proper research agenda, the lack of communication between researchers and policy-makers, and scarce funding in the region.^18,30,31

In LAC countries, the overall production of COVID-19-related publications focused on diagnosis/treatment (27.4%), which is in consistent with what has been described in previous bibliometric studies conducted in the region.^12-14 However, in the subgroup analysis, where only original articles were assessed, the main area of research was actually epidemiology/surveillance (24.15%), which differs from the findings by Gianola et al.³ in a study addressing the characteristics COVID-19-related scientific publications worldwide, where the most common research area was COVID-19 prevention and control (26.1%). As the pandemic progresses, other areas such as early detection and prevention, diagnosis and treatment, and health care delivery should be prioritized, so that efforts to alleviate the crisis in the region are more directly informed.¹⁹

Our study has several strengths. The first is the comprehensive quantification and mapping of the research conducted in LAC, which is a well-defined worldwide as the epicenter of the COVID-19 pandemic. Our study also included the LILACS database, which is a region-al search engine that includes publications that are not indexed in PubMed or Scopus, so the underreporting of COVID-19-related publications in LAC is less likely. In addition, excluding studies that did not use local data reduced the possibility of outcome misclassification bias, resulting in robust data to appropriately inform regional and national health policies.

Despite these strengths, some limitations should be mentioned, such as the fact that publications prior to January 2020 were excluded from this study; however, the first COVID-19 case in a LAC country was reported in February 2020, so the risk of misclassification is low. Moreover, bibliometric impact indicators, such as the H index or number of citations per article, were not evaluated and, instead, journal quartiles and specific research approaches were used to assess the impact of the contributions made in LAC.

Furthermore, only first and last author affiliations were included in the analysis, which may lead to an under-representation of LAC authors listed in other authorship positions, so future studies should evaluate all authorship bylines and their affiliations. Also, potential reliable evidence to inform clinical practice or evidence-based decision-making in the form of preprints could have been omitted from the present study; while we consider that preprints should be included in future studies, this type of non-peer-reviewed document should be approached with caution, as they could have an information bias, as previously reported.³²

Another shortcoming of the present study is that only three comprehensive databases (LILACS, PubMed and Scopus) were consulted to retrieve COVID-19-related publications conducted across the region, so eligible publications not indexed in these databases may have been omitted;^33,34 however, it is expected that any missed publication may have little impact because Scopus alone covers more journals than PubMed and Web of Science.³⁵ Also, disaggregate data regarding international collaboration among the publications on COVID-19 that were analyzed was not presented here, so future analyses should provide this important information. Finally, the COVID-19 publication trend found during the first half of 2020 may not reflect current scientific production across LAC, thus, findings should be interpreted with caution.

Our study has important regional decision-making implications that can help strengthen public policies and contribute to the scientific community in LAC. In this context, regional and local leaders and stakeholders should pay attention to the region's lack of original articles, and the pandemic should be reframed as an opportunity to increase the volume of high-quality research. Given the high burden of COVID-19 in LAC, this region is likely eligible for conducting clinical studies that may provide a better understanding of the disease and its course.^29,30 Therefore, local governments should also promote research by allocating funding and facilitating international and/or regional collaboration.

The pandemic is likely to continue in the long term, but there is limited literature on effective pharmacologic therapies; however, at the time of writing this manuscript, several vaccines for COVID-19 are already available under emergency use authorization, mostly in developed countries. Thus, besides increasing research in on the diagnosis and treatment of COVID-19, LAC countries should conduct more research on early detection and prevention, health care service delivery to patients with the disease, and evaluation of national programs implemented to combat the pandemic. While most regional governments anticipate that developed countries will seek long-term solutions to the COVID-19 crisis, LAC countries may have access to opportunities and initiatives that could contribute vital and valuable knowledge, both regionally and globally.

Conclusions

COVID-19 remains a global threat that requires immediate research attention, particularly in epicenter areas such as the LAC region. Researchers in this region have shown great interest in disseminating information internationally through the publication of works in high-impact journals; however, during the study period, non-original research articles predominated in the scientific production of the region, and among original articles, interventional studies were scarce, while cross-sectional predominated.

Researchers and policymakers in these countries must adopt the mindset that, in times of emergency and uncertainty, high-quality information is the best defense we have to prepare the world for this pandemic and others to come. Consequently, further research with a better quality of evidence should be performed in these countries to contribute to the formulation of health policies aimed at easing the burden of COVID-19 in the region and preparing for future pandemics.