The behavior of the porcine flu epidemic in Cuba is concerning

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                   Influenza A (H1N1) in Cuba:
             Questions and Unexpected Developments.

                        Antonio M. Gordon, Jr., M.D., Ph.D.

      Mailing Address: P.O. Box 523096, Miami, Florida 33152

      Word count for text only: 1799

      Running Head: Influenza-Cuba.

The Influenza A (H1N1) epidemic in Cuba has recently attracted international attention.
Despite official reports attesting to a very low level of activity in the first wave of the
pandemic and strict epidemiologic control measures established in the island in April,
Cuba reported 793 confirmed cases and 7 deaths from Influenza A (H1N1) as of mid-
October. (1)


On April 29, 2009, five days after Mexico reported the onset of the Influenza A (H1N1)
epidemic, Cuba closed all air traffic with Mexico. (2) Since summer all visitors entering
Cuba are being monitored for influenza-like-illness (ILI) and submitted to a thermal
scanning device and quarantined if any question of influenza exists. On October 4, 2009
according to the Associated Press, Cuban vice-minister of health Dr. Luis Estruch was
said to be unwilling to depend on the “uncertain and ineffective” porcine influenza
vaccine. (3) The official line at that time appeared to be that Cuba was doing well with
the influenza epidemic and it would fight Influenza A (H1N1) with its civil defense
system and sophisticated epidemiologic apparatus managed by the MINSAP. In view of
this background, it was somewhat unexpected that on October 9, 2009 Cuba reported six
deaths from porcine influenza complications out of 621 confirmed cases. (1) At least half
of the reported deaths were said be from pregnant women. Unofficial testimonials from
travelers and independent journalists in the island suggested that Cuban hospitals were
facing increasing admissions for ILI.

Had the virus mutated in Cuba? By early October posed a greater threat than before?
Margaret Chan who surveyed the situation in Havana in late October stated that the virus
has not mutated.(2) Assuming that the data presented to Dr. Chan are confirmed, several
questions remain unanswered. Is Cuba overstating the level of the epidemic in the island
to influence public opinion and the United States to lift the legendary economic embargo
against the Castro regime? Was the Cuban porcine influenza epidemic underreported or
under-diagnosed originally? If so, why or how come given the effectiveness and
reputation of the MINSAP? Are Cubans more susceptible than other populations to the
Influenza A (H1N1)?

The timeline of the Cuban influenza A (H1N1) epidemic suggests that Cuba perhaps
overreacted to the news of an outbreak of a new influenza virus in Mexico on April 24,
2009. Almost immediately, on April 29th, Cuba closed all travel and contacts with
Mexico. Soon thereafter, Cuban health officials claimed that Cuba was free from the
porcine flu. (3) However, by the middle of May a case of a Mexican student was reported
as the first case of porcine flu in the island. By June there were more cases attributed to
foreigners or Cubans who had traveled abroad. In July, the Cuban foreign ministry,
MINREX, reported increasing its surveillance of Influenza A (H1N1) as the number of
cases was increasing steadily in the island. (4,5) In August, the United States Interest

Section in Havana announced that Cuba had instituted epidemiologic surveillance and
control measures at all Cuban ports and airports to detect and isolate travelers infected
with Influenza A (H1N1). (6) No deaths were officially reported through the summer.

By September, however, there were unofficial reports that the city of Colón in central
Cuba was quarantined because of an outbreak of porcine influenza and some deaths had
occurred. Then, in the interval from October 2nd to the 9th, Cuba officially reported 6
deaths, three of them in pregnant women. It was then that the island health and political
officials, despite previous statements decrying the porcine influenza vaccine, requested
assistance from the WHO and the international community to acquire Influenza A
(H1N1) vaccine.(2) Soon thereafter a seventh death was officially reported.

Telephone interviews conducted with medical professionals and independent journalists
inside the island from October 10th through the 14th, 2009 and with workers in health care
facilities in the island ranging from infant and children care centers to hospitals suggest
that the epidemic in Cuba appears larger than expected form previous reports. The urban
centers are being hit disproportionately higher than the countryside. Infants and children
are being sent home from infant and children centers and schools at the earliest signs of
ILI. Workers are also being sent home with signs of ILI. The Cuban government has
enacted a decree, “Resolución 90,” through which both mothers who are kept home to
attend influenza ill children and workers with influenza receive their daily stipend while
kept out of circulation. (7)

In Colón, testimonials from the regional Mario Muñoz Hospital suggest that the facility is
overcrowded with patients suffering with the porcine flu and its complications. Pregnant
women seeking routine care from the hospital’s catchment area (Manguito, Jagüey
Grande, Jovellanos, Los Arabos, and Calimete) are currently being asked to travel to the
city of Matanzas, 90 kilometers Northwest of Colon because their regional hospital in
Colón is quarantined. An independent journalist reported that the largest hospital in the
provincial capital, the Faustino Pérez Hospital, only has seven working ventilators.
Considering that the population of Matanzas province is estimated at approximately three
quarter of a million persons, concerns exist about the adequacy of medical facilities in the
city of Matanzas to deal with the influenza epidemic.

In Havana, some hospitals have designated entire wards for the care of patients admitted
with Influenza A (H1N1). In some localities in the Cuban capital, entire apartment
buildings have been rapidly converted to house individuals who need isolation by Cuban
public health standards. Considering the ongoing exit of health professionals out of Cuba
as part of the countries involvement in providing health personnel to the developing
world, our sources (independent journalists) in Havana question how these hastily
arranged facilities are being staffed and what criteria are being used to triage patients
with ILI.

The official explanation for the increased porcine influenza activity and deaths in the
island is blamed on the importation of the virus from foreigners and travelers. According

to MINSAP, “30% of porcine influenza cases in Cuba are imported by tourism” (5). On
October 31st, 2009 Fidel Castro specifically blamed Cuban-Americans for importing the
virus into the island. (8)

A consideration of the number of tourists visiting the Caribbean (Table 1) and the number
of Influenza A (H1N1) deaths in the region suggests that other islands and tourist
destinations in the region should have been hit as hard or harder than Cuba by the porcine
influenza epidemic if tourism alone was responsible for the epidemic.
The data in the table suggest that it is not likely that the lethality of the influenza virus, a
marker of the prevalence of Influenza A (H1N1), cannot be explained by tourism alone (r
= - 0.16). With regards to Mexico, a country that has managed the public health aspects
and reports on the epidemic with remarkable openness and transparency (9), the level of
Influenza A (H1N1) activity reported by the Mexican Caribbean, the State of Quintana
Roo, is minimal (0.012%) compared with the more battled regions of Mexico.(10)
Therefore, it is unlikely that travelers and tourism by themselves have been the bases for
the rapid progression of the Cuban influenza epidemic.

Obviously, this discussion assumes all other variables including reporting, hygiene,
health facilities, host defenses and infectivity to be equal. Since the latest complete set of
tourist data for the region are from 2007, it is also assumed that the level of tourism has
not changed drastically in the Caribbean in the past 2 years.

If tourism is not to blame, what other issues may be considered to explain the
recrudescence of the Cuban porcine influenza epidemic? Has the effectiveness of the
“thermal scanning” and epidemiologic controls used been studied and reported? No. Is
the Cuban population more susceptible to the porcine flu than expected? Possible. Have
the Cuban earlier reports under-diagnosed or underreported the epidemic in the island?

Indeed, Cubans at this time may be more susceptible to the Influenza A (H1N1) virus
than expected from both the infectious diseases and nutritional points of view. Dengue is
endemic in the island and co-infection with various strains of dengue virus with the
possible development of hemorrhagic complications may present a formidable problem.
Furthermore, an epidemic illness associated with nutritional deficiencies would not be
new to the island. Cubans have been on a fairly monotonous dietary regimen, particularly
in urban centers, controlled by the “libreta de racionamiento” (rationing booklet) since
March 1962 and the black market, particularly since the dissolution of the former Soviet
Union. A thorough review of Cuba’s nutritional needs must be undertaken with specific
attention to the micronutrients such as iron, zinc, selenium whose deficiencies may lead
to immune dysfunction.

The United States embargo imposed since 1962 may also be implicated as a negative
factor in Cuban nutriture. However, the embargo has been softened in the past decade
allowing Cuba to purchase American food products with cash. On the other hand, the
failure of Cuban agriculture is one of the most urgent and concerning issues in Cuba
today. Presently, Cubans import 80% of the food they consume.

Lastly, consideration of transparency or lack thereof in public health in Cuba is in order.
The rhetoric of Cuban officials prior to October 9th claiming self-sufficiency and
decrying the available porcine influenza vaccine produced globally in record time seems
inappropriate but it was also most unexpected in view of their subsequent turn around
through which the Influenza A (H1N1) was requested. Questions on the lack of
transparency and openness in matters of public health must be raised.

In terms of transparency, it is well known that socio-economic conditions in Cuba’s
urban centers at present are deplorable. For the past twenty years Cubans frequently have
cohabitated in urban centers with chickens and pigs in various types of dwellings
including apartments with marginal hygienic measures. Under these circumstances it
does not seem necessary to invoke the entry of the Influenza A (H1N1) virus through
tourists or Cubans visiting the island.

In summary, the Influenza A (H1N1) epidemic seems to have recrudesced in Cuba to the
extent that healthcare facilities are being overwhelmed and an increasing number of
deaths have been officially reported. Despite official claims, tourism is unlikely the cause
of the surge in the level of activity of Influenza A (H1N1) in Cuba. A strong
consideration for openness in all these matters and transparency in public health issues
are in order. Margaret Chan has already included Cuba among the developing countries
that will receive Influenza A (H1N1) vaccines. In early November 2009 Cuba has begun
to administer seasonal influenza vaccine to high-risk groups. Still, however, even after
the provision of effective vaccines, serious questions about the immune and micronutrient
status of the Cuban population are raised with the hope of directing the interest, policy,
resources and future studies to minimize the impact of the porcine influenza in Cubans.

Table 1. Summary of recent tourism statistics in most visited Caribbean destinations.

    Tourist Caribbean              Visitors in millions*          Reported Influenza A
       Destination                                                  (H1N1) deaths °

       Bahamas                              4.4                              4
   Dominican Republic                       3.9                             22

   Mexican Caribbean §                       2.4                              1
          Cuba                               2.1                              7
    Cayman Islands                           1.7                              1
        Jamaica                              1.7                              5
      Puerto Rico#                           1.7                             39
      St. Maarten                            1.4                              0

   * Data for 2007, latest year available. ( Accessed Oct 2009)
   ° Data as of 26 October 2009 according to WHO.
   ( Accessed Oct. 2009)
   §. Ref. (12).
   #. Actualización Influenza A H1N1 y Dengue. Press Release. Department of Health
   of Puerto Rico. 20 October 2009.


The porcine influenza epidemic in Cuba has recently attracted international attention.
Despite the reputation of Cuban public health, a very low level of activity in the first
wave of the pandemic and strict epidemiologic control measures established very early in
the island, the Influenza A (H1N1) epidemic seems to have recrudesced in the island.
With this background, the WHO Director-General Dr. Margaret Chan visited the island
and has already stated that the Influenza A (H1N1) virus has not mutated. The timeline
of the Cuban porcine influenza epidemic is reviewed along with Cuban official data and
reports form Cuban health care workers and independent journalists in the island
contacted via telephone interview. Cuban children are being sent home form care centers
and schools at the earliest sign of an influenza-like-illness. The same appears true for
workers. At least a provincial hospital in central Cuba is already being bypassed because
it is full to capacity. In the Cuban capital, hospitals have set up isolation wards and entire
apartment buildings are being hastily prepared to house persons infected with Influenza A
(H1N1) who may need hospitalization. Cuban health authorities have not officially
recognized the latter. Healthcare facilities in the island do appear seem overwhelmed and
an increasing number of deaths have been officially reported. A case is made for
openness in these matters, transparency in public health in the island and further studies
to determine if Cubans are at higher risks than others to succumb to the porcine influenza.


1. Cuba announces first swine flu deaths. October 9, 2009.
FpNLdcNUPA. Accessed October 10, 2009.

2. Elogia Margaret Chan, directora general de la OMS, sistema de salud cubano. Accessed October 28, 2009.

3. Cuba gets ready for confront second flu wave (Granma Internacional). October 2,
2009. Accessed October 28, 2009

4. Global Alert for A-H1N1 Influenza. Cuba free of infection. May 5, 2009.
cuba_free_infection.html. Accessed October 10, 2009.

5. MINSAP's International Sanitary Control (CSI) agency has boosted epidemiologic
surveillance at national and international airports, ports and marinas.
5_1.html. Accessed October 28, 2009.

6. United States Interests Section, Havana, Cuba. Warden Message No. 2 2009
(H1N1 Influenza). August 27, 2009.

7. Facing Influenza A H1N1: Work and Wage Protection for Cuban Workers.
October 28, 2009.
cuba102809.html. Accessed October 29, 2009.

8. Castro Says Increased US Visits Helped Spread H1N1 in Cuba. VOA News. 01
November 2009.

9.Stern AM, and Merkel H. What Mexico Taught the World About Pandemic
Influenza Preparedness and Community Mitigation Strategies. JAMA 2009. 302(11):

10. Mexico’s National institutes of Public Health.
Accessed October 27, 2009.

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