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1 Influenza-Cuba 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. 2 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) Background.- 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 3 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 4 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? Unknown. 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. 5 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 6 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. (www.onetourism.org Accessed Oct 2009) ° Data as of 26 October 2009 according to WHO. (http://www.sld.cu/sitios/influenzaporcina/ Accessed Oct. 2009) §. Ref. (12). #. Actualización Influenza A H1N1 y Dengue. Press Release. Department of Health of Puerto Rico. 20 October 2009. Abstract.- 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. 7 References. 1. Cuba announces first swine flu deaths. October 9, 2009. http://www.google.com/hostednews/afp/article/ALeqM5izMtVXUSAR7rYdp2Z- FpNLdcNUPA. Accessed October 10, 2009. 2. Elogia Margaret Chan, directora general de la OMS, sistema de salud cubano. http://new.paho.org/cub/. Accessed October 28, 2009. 3. Cuba gets ready for confront second flu wave (Granma Internacional). October 2, 2009. http://www.cuba.com/local_news.php?id=5089. Accessed October 28, 2009 4. Global Alert for A-H1N1 Influenza. Cuba free of infection. May 5, 2009. http://www.cubaheadlines.com/2009/05/05/17010/global_alert_ah1n1_influenza_ 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. http://www.cubaminrex.cu/English/LookCuba/Articles/ScienceTechnology/2009/052 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. http://www.periodico26.cu/english/health/july2009/influenza- 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): 1221-2. 10. Mexico’s National institutes of Public Health. http://portal.salud.gob.mx/contenidos/noticias/influenza/estadisticas.html. Accessed October 27, 2009.
"The behavior of the porcine flu epidemic in Cuba is concerning"