Cuba's long-standing commitment to health has led to a successful COVID-19 pandemic response, but it is threatened by financial and supplier issues. Talha Burki reports.
As The Lancet Infectious Diseases went to press, Cuba was due to launch a phase 3 trial of its subunit conjugate vaccine against COVID-19. Soberana-2 is one of four candidate COVID-19 vaccines in development in Cuba. It is produced by the Finlay Institute in Havana. On the basis of as-yet-unpublished results from early-stage clinical trials, Vicente Verez-Bencomo, director-general of the Finlay Institute, expects the vaccine to show an efficacy in the region of 80–95%. “We are very optimistic”, he said. If everything goes according to plan, Cuba could start a mass vaccination programme for its 11·2 million citizens sometime in the summer.
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After keeping SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) at bay for most of 2020, Cuba has experienced a surge of infections in 2021. As of March 8, the country had reported 55 693 cases of COVID-19 and 348 deaths. 23 093 new cases occurred in February alone, almost twice as many as occurred in the whole of 2020. Cuba is still doing far better than the majority of other countries in the region, but a vaccine is urgently needed.
A second phase 3 trial of Soberana-2 is planned for Iran, as part of a partnership between the Finlay Institute and the Pasteur Institute of Iran. A phase 2/3 trial has been scheduled for Soberana-1, which was also developed by the Finlay Institute. The Center for Genetic Engineering and Biotechnology (Havana, Cuba) is behind the other vaccine candidates. Abdala and Mambisa, a nasal spray, both entered phase 1/2 trials late last year.
Soberana means sovereign in Spanish. Abdala is the title of a poem by a Cuban revolutionary, and Mambisa is named after the guerrillas who fought against the Spanish colonialists in the 19th century. All of which indicates that the vaccine drive is a matter of national pride. President Miguel Díaz-Canel has visited the Finlay Institute three times over the course of the COVID-19 pandemic. At home and abroad, post-revolutionary Cuban identity has always been bound up with health. In 1960, Cuba joined the relief effort after the Chilean earthquake. In 1963, it sent health-care workers to assist the newly independent state of Algeria.
Cuba's Henry Reeve Brigade was established in 2005. It has despatched cadres of health-care professionals all over the world to combat disasters and epidemics. Cuban doctors were on the scene in Haiti during the cholera outbreak that followed the 2010 earthquake; they arrived in west Africa during the 2013–16 Ebola crisis. And when COVID-19 spread to Europe, two Henry Reeve teams landed in Italy. By the end of April, 2020, more than 1000 Cuban health-care workers were helping foreign countries respond to COVID-19.
“The international health programme is about solidarity; Cuba believes that healthy populations are the bedrock of global society and they want to support that any way they can”, said Clare Wenham, assistant professor of global health policy at the London School of Economics and Political Science (London, UK). Malaria, polio, tetanus, and measles have been eradicated in Cuba. The island's successful response to COVID-19 was largely a result of years of investment in primary care and assiduous attention to population health. The country has comprehensive universal health care and one of the highest doctor to patient ratios in the world.
Doctor and nurse teams are embedded in the local community. “Everyone has a yearly routine check-up, and if you do not go, the doctor will come and find you”, Wenham told The Lancet Infectious Diseases. “It means physicians proactively identify problems; there is a real emphasis on prevention.” Disease outbreaks can be detected more or less immediately. Under a model known as CARE, patients are stratified into four categories: apparently healthy, at risk of disease, unwell, and in rehabilitation or recovery. Those at risk of disease include individuals who are overweight, have diabetes, or hypertension. When Cuba registered its first case of COVID-19 on March 11, 2020, it already knew the whereabouts of its most vulnerable citizens.
In an interview with MEDICC Review, family physician Marta Gálvez outlined the advantages of the Cuban system: “The first thing any self-respecting doctor must know is the health situation of the population she serves”, she explained. “The main goal of a primary care physician is health promotion and prevention of diseases, so you have to know your community to design a strategy that suits their needs. CARE is a vital tool: it's why I know that I have 658 older adults in a total population of 1093 people, and 42 of the elderly live alone.” Roughly one in five Cubans are over the age of 60 years.
“The public health network is very strong in Cuba, but it comes at the cost of civil liberties”, said Wenham. “Cuba is a very specific context; not many countries are going to accept that kind of close medical surveillance, and most governments do not have such tight control over their citizens.” After SARS-CoV-2 entered the island, more than 28 000 medical students led an active screening programme that within a few weeks had reached 9 million Cubans. Cuba had started preparing well in advance of its first case of COVID-19. It quickly shut its borders and set up isolation centres and an efficient system of test-and-trace. But soon after Cuba opened up late last year, cases began to rise.
The pandemic has been extremely expensive. Gross domestic product shrunk by 11% in 2020. Instead of the usual 4 million tourists, Cuba played host to just 80 000. The long-standing economic blockade imposed by the USA has taken a heavy toll. “Health centres and clinics face regular stock outs of basic drugs, such as paracetamol, and other equipment such as bandages”, notes Fiona Samuels, senior research fellow and honorary associate professor at the London School of Hygiene & Tropical Medicine (London, UK). “The staff are very well trained, but the health infrastructure is decayed and they often lack the basics to allow them to do their work effectively.”
Cuba's biotechnology industry sprang up in response to the US blockade. It consists of more than 30 research institutions and manufacturers, under the aegis of the state-run conglomerate BioCubaFarma. In the late 1980s, Cuba developed the world's first meningococcal B vaccine. It produces eight of the ten routinely used vaccines in the country, and sends hundreds of millions of doses abroad. But obtaining raw materials is a constant struggle, especially in the aftermath of the hardening of the American sanctions during Donald Trump's presidency. “You have situations where suppliers of important components for our industry for several decades have been obliged to suddenly stop; it makes everything more expensive and complicated, and it is real concern”, said Verez-Bencomo. Tourism brings in a flow of much-needed currency, especially since Cuban-Americans have been barred from sending remittances, but with the tourists comes the virus. The Cuban Government reckons that more than 70% of current cases of COVID-19 are linked to new arrivals in the country.
If Soberana-2 proves successful, Cuba plans to export it at low cost after the national vaccination efforts have finished. The centralised health-care system means the domestic rollout is unlikely to be problematic, although pockets of the island are tricky to access. Verez-Bencomo reckons that by the end of the summer the country will have the capacity to produce 10 million doses of vaccine per month. Cubans are excited about the endeavour. “When we call for volunteers for clinical trials, we always have two or three times as many people as we need coming forward”, said Verez-Bencomo. “On the street, everywhere I go, everyone is asking about the vaccine.”
by Talha Burki
COVID-19 pandemic in Cuba
From Wikipedia, the free encyclopedia
The COVID-19 pandemic in Cuba is part of the worldwide pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The virus was confirmed to have spread to Cuba on 11 March 2020 when three Italian tourists tested positive for the virus.
On 12 January 2020, the World Health Organization (WHO) confirmed that a novel coronavirus was the cause of a respiratory illness in a cluster of people in Wuhan City, Hubei Province, China, which was reported to the WHO on 31 December 2019.[5][6]
The case fatality ratio for COVID-19 has been much lower than SARS of 2003,[7][8] but the transmission has been significantly greater, with a significant total death toll.[9][7]
Cuba faces multiple domestic challenges in its response to the ongoing pandemic. Health professionals are facing challenges including shortages of medical supplies, poor sanitary conditions, and low wages. Cuba also has one of the oldest populations in the Americas and one quarter of the population is considered at-risk. Additionally, Cuba's economy is suffering due to the global decrease in tourism amid the pandemic. As a consequence, the government began increasing centralization of the economy in an effort to prevent a deeper economic crisis like the one experienced by the country after the end of the Cold War.[10]
Cuba's policy of “medical internationalism” has played a prominent role in the country's response to the COVID-19 crisis. Cuba sent medical personnel to the hardest-hit Italian wealthy region of Lombardy,[11] as well as Angola and a dozen Caribbean states including Suriname.
Cuba has engaged effective COVID-19 preventive measures, and despite the concurrent economic crisis and shortages of consumer products, officials have reporter that the country's population has only suffered minimal losses. Regular testing, wearing of face masks, and health visits by nursing professionals have kept the reported case loads and mortality rates lower than in most countries of the Americas.
Timeline
March 2020
On 11 March, the first three cases in Cuba were confirmed. The patients were Italian tourists. They were kept in isolation at the Pedro Kouri Tropical Medicine Institute in Havana.[13]
The government urged citizens to make their own face masks, while the textile industry was drafted to fabricate them. People were advised to carry several cloth face masks with them, depending on how many hours they plan to spend in public areas.[4]
On 12 March, a fourth confirmed case was announced. This was a Cuban, whose wife had arrived from Milan, Italy on 24 February, and who had started showing symptoms on 27 February. The husband had begun to show symptoms by 8 March. Both were tested and he was positive. The wife was stated to be negative because the disease had run its course.[14]
On 16 March, the cruise ship MS Braemar, with over 1,000 passengers and crew on board, was given permission to berth in Cuba after being rejected by the Bahamas. At least five passengers have tested positive for coronavirus (COVID-19). British citizens were able to take flights home after both governments reached an agreement on their repatriation.[15]
On 17 March, the number of confirmed cases increased to 7.[16]
On 18 March, the number of confirmed cases increased to 10, and the first death was announced, a 61-year old Italian who had been one of the first three confirmed.[17]
On 19 March, the number of confirmed cases increased to 16.[18]
On 20 March, the number of confirmed cases increased to 21.[19] Also, it was announced that Cuba will restrict entry to residents with effect from 24 March.[20] Only Cuban residents may enter, that is, if they have not been outside of Cuba for more than 24 months; as well as foreigners residing on the island.[21]
On 22 March, the Ministry of Public Health (MINSAP) of Cuba raised the number of coronavirus infections on the island to 35 but were monitoring more than 950 suspected cases, according to information published by the state agency on its website.[22]
On 23 March, authorities in Cuba raised the number of coronavirus patients to 48.[23]
On 24 March, the Cuban government closed all schools until at least 20 April.[24]
Visitors who arrived between 17 and 23 March were required to be tested for the coronavirus.[25]
As of 30 March, the number of confirmed coronavirus cases was at 170, with 4 deaths.[26]
April 2020
With effect from midnight on 1 April, Cuba suspended the arrival of all international flights.[27]
On 4 April, authorities in Cuba raised the number of coronavirus patients to 288.[28]
As of 15 April, there were 755 cases of COVID-19 in Cuba, there were 18,856 total tests done so far[29]
May 2020
As of 12 May, new cases had fallen to less than 20 per day, and a program of mass testing was beginning.[30]
As of 30 May, the city of Havana represented slightly more than half of the total confirmed cases.
