IISC researcher Marcel Kunzmann on how Cuba brought Covid under control

Cuba and Covid: an update

Cuba and Covid: an update

By Marcel Kunzmann, IISC researcher

When Cuba was in the headlines in the summer because people in several towns and cities had taken to the streets in protest at the government, one of the demands being heard from the protestors was for vaccines. At that time, the Delta variant was rising alarmingly in some areas of the country and Cuba’s vaccination campaign, using its own homemade vaccines, had only just begun. In a few short months the situation has now changed. Cuba has brought the virus under control, has become one of the most vaccinated countries in the world and reopened its borders for tourism. Here, IISC researcher, Marcel Kunzmann, explains the situation and how and why Cuba, a country that was labelled as a ‘failed state’ by the US administration, has managed this transformation. 

Picture: Fruto de la revolución by Roberto Fumagalli

More than three weeks after the opening to tourism on 15 November, incidences of Coronavirus infection in Cuba are falling dramatically. Despite the increase in visitors, at the time of writing, the situation on the island remained stable: for the first time, the 7-day incidence was back in single digits, and the intensive care units were empty. This is mainly due to the vaccination campaign, which has now reached nine-tenths of the population. Still, Cuba’s health authorities are worried about the new Omicron variant, which has so far been detected in 57 countries. 

On 8 December, Cuba reported its first case of the variant. One of the two vaccine manufacturers has already started adapting its vaccine. “Even in the face of the new variant, we will not close our borders,” President Miguel Díaz-Canel made clear in a statement on 30 November. All feasible precautionary measures were to be taken, he added, with new entry rules for risk areas coming into force in the following few days. 

The first Omicron case was a doctor from Pinar del Río who brought the variant with him on his return from Mozambique. He had entered the country on 27 November, before the new quarantine rules for travellers from sub-Saharan Africa came into force. On 28 November, he was admitted to the “León Cuervo Rubio” hospital in Pinar del Río after first symptoms appeared. When the PCR test was further sequenced on 8 December, the new variant was finally identified. 16 contacts outside the person’s household had all tested negative by PCR. A first suspected case of a passenger from South Africa previously proved to be a false alarm on 3 December. There is still a lack of reliable data on the transmissibility and severity of the variant. Despite the good figures, Omicron is already making one thing clear: for Cuba, too, the pandemic will only be over when the situation is under control worldwide – and the availability of vaccines is therefore playing the most important role.

On 7 December, a total of 963,347 people had tested positive for SARS-CoV-2 in Cuba. This was an increase of 78 from the previous day. By that date, 8311 people had died as a result of the virus, but the number of deaths has now fallen drastically. There were no new deaths reported from the previous day. 2,904 people were in medical facilities for health monitoring, 954,572 were considered to have recovered. The number of active cases was currently 407, of which 16 were receiving intensive care. Case mortality remains at 0.86 per cent, well below the global average. In contrast the rate for the UK was 1.4%, the US 1.6% and Brazil 2.8%, according to the Johns Hopkins Covid database.

The decline in the infection rate predicted by Cuba’s modellers has continued in recent weeks and the highest case numbers are no longer reported in Havana and Pinar del Río but in the eastern province of Holguín. Cuba’s health authorities urged “responsible coexistence” with the virus at the last meeting of the crisis management team, saying the fight against the pandemic is far from over despite the encouraging figures.

The 7-day incidence per 100,000 inhabitants has massively declined since mid October from 245.9 (15 October) to 6.8 (12 December), reaching single digits for the first time since last year. The number of PCR tests performed was reduced from 31,000 to 17,500 per day over the same period.

The vaccination campaign: A community-based collective approach 

Cuba’s vaccination campaign is based upon its socialist health care system that prioritizes citizen participation and collective health. Despite the harsh economic conditions in recent years that also affected the quality of public services, the system performed solid in rolling out the vaccines. As with other health initiatives, such as the anti-dengue fever drives, the country counts on its networks of mass organizations, primarily the “Committees for the Defence of the Revolution” (CDRs), which have a local cell in every neighbourhood, and the Women’s Federation (FMC). These receive lists of citizens scheduled for vaccination in their area. Their members then go door to door informing the citizens of the place and time of their appointment. The vaccinations are administered by the 18,000 family doctors’ practices nationwide. Doctors are required to vaccinate all of the doses supplied within the specified period and, in the event of cancellations, to find others willing to be vaccinated at short notice. As in other countries vaccination is by groups based upon their risk of complications from infection, priority is also given to age groups: The first group to be vaccinated were people over 60, then from mid-June those aged 40 to 59, and finally everyone over 19. Pregnant women, people with high blood pressure and cancer patients are currently excluded from vaccination, while the “Soberana 02” vaccine received emergency approval for children above the age of 2 on September 3rd. Before the start of the new school year in late October, more than 90 percent of Cuba’s children have received at least the first dose. Unlike in the UK and Germany for example, education facilities were not opened until the vast majority of pupils and students have been reached by the campaign. In this way it is hoped that infections will be held down. 

As the first and so far only country in Latin America, Cuba has succeeded in developing its own vaccines against the coronavirus. The “Soberana” vaccine family was developed by the Finlay Institute for vaccine development in Havana, while “Abdala” was created by the Centre for Genetic Engineering and Biotechnology (CIGB). Phase-I trails started in August 2020, Phase-III with 50.000 participants per vaccine candidate concluded in June 2021. The vaccination campaign began as part of a broad clinical intervention a few weeks earlier with “Abdala”. As of December, “Abdala”, “Soberana 02” and “Soberana Plus” (designed as a booster shot) have received emergency approval while the two institutes developed in total five vaccine candidates. All of them belong to the group of protein-based vaccines, in which a virus particle from the spike-protein is supposed to induce the immune response. They are based on technology Cuba’s been using for decades: a hepatitis B vaccine in the case of Abdala and a tetanus vaccine in the case of Soberana. Unlike mRNA vaccines, they can be stored at refrigerator temperature (2 to 8 degrees). They require 3 doses to achieve the desired efficacy.

By 10 December, 90.2 percent of Cubans had received at least the first shot (this represents more than 96% of the vaccine-eligible population aged two years and older). 83.7% of the population was fully vaccinated. This means that Cuba’s vaccination campaign has now left most industrialized countries behind and is second only to the United Arab Emirates in the percentage of the population that has received at least one dose. In terms of doses administered per inhabitant, Cuba leads the world due to the three-dose schedule. However, the goal of fully immunizing 90 percent of the population by the end of November was missed. In the meantime, booster vaccinations have begun on the island, initially for health care workers and those in the tourism industry. The administration for the general population took off December 6, starting in Havana: In the municipalities of Regla, Guanabacoa, Habana del Este and San Miguel del Padrón, around 33,000 people had received the 4th injection by the beginning of the month. The vaccination campaign started there in May, so the first vaccination was the longest ago. A total of 424,113 booster vaccinations had been administered by the time of writing. As the manufacturers announced, the two vaccine families used are interchangeable, so people vaccinated with “Soberana” can be boosted with “Abdala” and vice versa. Long-term studies on the duration of immune protection are currently underway to determine the best possible interval for future booster vaccinations. Another study is testing the effectiveness of the nasally administered vaccine “Mambisa” as a booster.

The reason for the Cuban success has partly to do with the high esteem in which Cubans generally hold their medical services and in particular the trust they have in their local doctor and health care system despite its material shortcommings. Because its primary health care is so extensive, citizens have a personal relationship with their local doctor who lives in their neighbourhood and will have between 1,400-2,500 patients in total to care for. Cuba already mass vaccinates children against 13 diseases and therefore the population is used to receiving them. Uptake of the vaccines is voluntary and there is no anti-vax movement in Cuba. From a public health perspective, the proactive approach in organizing vaccine appointments for the population instead of leaving the initiative to the individual, along with the close connection of family doctors to their communities, could have been a key for the high uptake rate.

“Useful addition for the world”: Recognition for Cuba’s vaccines

The renowned scientific journal Nature recently devoted itself to Cuba’s self-developed vaccines. The article by Sara Reardon makes reference to the latest preprint study on the Soberana vaccines, in which an efficacy of 92.4 percent against symptomatic infections caused by Delta was proven. John Grabenstein, president of Vaccine Dynamics, a consultancy at the University of North Carolina, described Cuba’s vaccines in the article as a “useful addition for the whole world”. The data available so far would appear solid: “Everybody’s using a different tool out of the toolbox, and they pretty much are all working,” Grabenstein said. In a solemn ceremony, President Díaz-Canel thanked the developers: “You, together with the health workers, have saved the country. Cuba will never forget that,” said the head of state.

In the meantime, Cuba’s scientists have started adapting their vaccines to the new variant. “We decided last week to produce a variant of Soberana Plus with the receptor-binding domain of the Omicron spike-protein,” said the director of the Finlay Institute for Vaccine Development (IFV), Vicente Vérez Bencomo. The first proteins have already been synthesized. Everything is being done to “stay ahead of any possible situation”, Vérez Bencomo assured. As Eduardo Martínez Díaz, head of the state pharmaceutical umbrella company BioCubaFarma, announced, work is being done in parallel on the design of new vaccines specifically against Omicron.

“Soberana 02” was the first vaccine to be approved for the age group of two years and older. At the end of October, Cuba’s medical regulator CECMED had granted emergency approval to the “Abdala” vaccine for the age group 12 to 18. This means that both Cuban vaccines can be used in children and adolescents. Most recently “Soberana Plus” has also received emergency approval for convalescents aged two years and older.

Exports pick up speed

As the manufacturer “BioCubaFarma” announced on 22nd of September, Cuba has finished producing all the vaccine doses for immunizing its population. By the end of September, 30 million units of “Abdala” had been produced, and 7 million of Soberana 02. Daily production output of Soberana 02 is currently at 300,000 doses according to official figures. This allows Cuba to begin exporting it’s vaccines. By the end of the year, Venezuela will have received 16 million doses of the Abdala vaccine. From January 2022, the South American country wants to be able to produce the vaccine itself. Meanwhile, exports to other countries are just beginning. Besides Iran (where part of the studies for Soberana 02 were conducted), the most important initial customers include Vietnam, Nicaragua, Mexico and Argentina. Some of these countries are also planning to set up their own production lines. One obstacle to worldwide marketing is likely to be the continued lack of WHO approval; according to the latest information as of 11 November, three monts after the first talks the process is still in its very early stages. With a price tag of 6,5 US$ per shot, “Abdala” is just slightly more expensive than Britain’s AstraZeneca but significantly more affordable than Biontech-Pfizer, whose vaccines cost about 19.5 US$ and even undercutting Sputnik which is priced at 10 US$. Cuba’s Covid vaccines could be a viable offer for developing countries around the world for years to come. 

After the island had already publicly announced the launch of vaccine exports and shortly before the protests planned for 15 November, the United States offered Cuba a shipment of one million vaccine doses. Foreign Minister Bruno Rodríguez expressed surprise at the timing. In the summer, when vaccine, injection needles and other medical equipment were urgently needed, Washington had been much less generous and “did not consider even a basic humanitarian easing of the economic sanctions on the island”, he said. Cuba is currently in no need of US help as far as vaccines are concerned, Rodríguez responded. The country politely declined the offer and instead proposed to double the US supply to two million doses with the help of Cuban vaccine, which would be administered by a joint medical brigade of both countries in countries of the Global South as a sign of cooperation. The Biden administration did not accept the proposal.