Prevalence of intestinal parasites and associated risk factors among schoolchildren from Unión de Reyes municipality, Matanzas Province, Cuba

Intestinal parasites are widely distributed around the world and children are the most common affected group. The prevalence of intestinal parasites and associated risk factors by a cross-sectional study among children at a primary school in the Union de Reyes municipality, Matanzas province, Cuba, was carried out during April-May, 2022. Blastocystis spp. and Giardia intestinalis were the most common parasites found.

"Havana Syndrome": A post mortem

BACKGROUND

Since 2016, an array of claims and public discourse have circulated in the medical community over the origin and nature of a mysterious condition dubbed "Havana Syndrome," so named as it was first identified in Cuba. In March 2023, the United States intelligence community concluded that the condition was a socially constructed catch-all category for an array of health conditions and stress reactions that were lumped under a single label.

AIMS

To examine the history of "Havana Syndrome" and the many factors that led to its erroneous categorization as a novel clinical entity.

METHOD

A review of the literature.

RESULTS/CONCLUSIONS

Several factors led to the erroneous classification of "Havana Syndrome" as a novel entity including the failure to stay within the limitations of the data; the withholding of information by intelligence agencies, the prevalence of popular misconceptions about psychogenic illness, the inability to identify historical parallels; the role of the media, and the mixing of politics with science.

LAENALS: epidemiological and clinical features of amyotrophic lateral sclerosis in Latin America

OBJECTIVE

The Latin American Epidemiologic study of ALS (LAENALS) aims to gather data on ALS epidemiology, phenotype, and risk factors in Cuba, Chile, and Uruguay, to understand the impact of genetic and environmental factors on ALS.

METHODS

A harmonized data collection protocol was generated, and a Latin-American Spanish language Register was constructed. Patient data were collected in Uruguay in 2018, in Chile from 2017 to 2019, and in Cuba between 2017 and 2018. Statistical analysis was performed using SPSS 25.0.0 software. Crude cumulative incidence, standardized incidence, and prevalence were calculated in the population aged 15 years and older.

RESULTS

During 2017-2019, 90 people with ALS from Uruguay (55.6% men), 219 from Chile (54.6% men), and 49 from Cuba (55.1% men) were included. The cumulative crude incidence in 2018 was 1.73/100,000 persons in Uruguay, 1.08 in Chile and 0.195 in Cuba. Crude prevalence in 2018 was 2.19 per 100,000 persons in Uruguay, 1.39 in Chile and 0.55 in Cuba. Mean age at onset was 61.8 ± 11.96 SD years in Uruguay, 61.9 ± 10.4 SD years in Chile, and 60.21 ± 12.45 SD years in Cuba (p = 0.75). Median survival from onset was 32.43 months (21.93 - 42.36) in Uruguay, 24 months (13.5 - 33.5) in Chile, and 29 months (15 - 42.5) in Cuba (p = 0.006).

CONCLUSIONS

These preliminary data from LAENALS confirm the lower incidence and prevalence of ALS in counties with admixed populations. The LAENALS database is now open to other Latin American countries for harmonized prospective data collection.

Detection, Characterization and Sequencing of BTV Serotypes Circulating in Cuba in 2022

In Cuba, despite a high sero-prevalence of bluetongue virus (BTV), circulating serotypes remain unknown. The aim of this study was to identify circulating BTV serotypes in farms throughout the western region of Cuba. Blood samples were collected from 200 young cattle and sheep between May and July 2022 for virological analyses (PCR, viral isolation and virus neutralization) and genome sequencing. The results confirmed viral circulation, with viro-prevalence of 25% for BTV. The virus was isolated from 18 blood samples and twelve BTV serotypes were identified by sequencing RT-PCR products targeting the segment 2 of the BTV genome (BTV-1, 2, 3, 6, 10, 12, 13, 17, 18, 19, 22 and 24). Finally, the full genome sequences of 17 Cuban BTV isolates were recovered using a Sequence Independent Single Primer Amplification (SISPA) approach combined to MinION Oxford Nanopore sequencing technology. All together, these results highlight the co-circulation of a wide diversity of BTV serotypes in a quite restricted area and emphasize the need for entomological and livestock surveillance, particularly in light of recent changes in the global distribution and nature of BTV infections.

Quality of care for patients with ST-segment Elevation Myocardial Infarction before COVID-19 pandemic in Cuba: review of 17 reports with 7823 patients

BACKGROUND

In Cuba, there is neither a registry of ST Elevation Myocardial Infarction (STEMI), nor are analysis of performance measures widely reported.

OBJECTIVE

A review of Cuban studies of patients with STEMI was carried out to describe quality of medical care.

METHODS

Cochrane Library, EMBASE, PubMed, Scopus and SciELO, as well as archives of national journals, were all searched for articles on STEMI in Cuba, from 2000 to March 2020. They were included if they reported number or percentage of application of reperfusion therapy; administration of aspirin, enalapril-captopril (ACEI) or beta-blockers; status of patients at discharge; and patient or system delay times. Finally, 17 reports with 7823 patients were included.

RESULTS

Thrombolytic therapy was administered to 3991 patients (51%), and 695 patients (8.9%) died. Only four studies, with 880 patients, presented data about prescription of ACEI, aspirin, and beta-blockers, which were administered to 381 (45.3%), 824 (93.6%), 464 (52.7%) patients, respectively. Coronary intervention was reported in 5 studies with 3422 patients, being performed in 661 (19.3%).  Conclusions: Quality of care of patients with STEMI seems to be poorer than reported in similar scenarios. Thrombolytic administration is still low, although mortality decreases in this period. Other pharmacological treatments were insufficiently fulfilled.

First molecular characterization of Dirofilaria Immitis in Cuba

BACKGROUND

Dirofilarioses are widespread diseases caused by mosquito-borne nematodes of the family Onchocercidae, genus Dirofilaria. The major etiologic agent of canine dirofilariosis in the American continent is the zoonotic parasite Dirofilaria immitis. Existing reports of filarioid nematodes in Cuba are based solely on morphological and immunological analysis which do not allow unambiguous identification and/or direct detection of causal agents.

RESULTS

Here we present the molecular characterization of filarioid nematodes found in a dog in Cuba. Based on the molecular and phylogenetic analysis of the 5.8S-ITS2-28S region and cox1 gene fragments, the worms were unambiguously classified as D. immitis. Sequence analysis showed high identity of the gene fragments in this study with others previously obtained from D. immitis found in dogs, wolfs and jackals but also from mosquito vectors of D. immitis.

CONCLUSIONS

Further studies are guarantee to better understand the epidemiological impact of canine dirofilariosis in Cuba as well as the competence of different species of culicid mosquitoes as vectors of Dirofilaria in the country.

Exploring the natural history of intrinsic capacity impairments: longitudinal patterns in the 10/66 study

BACKGROUND

intrinsic capacity (IC) is a construct encompassing people's physical and mental abilities. There is an implicit link amongst IC domains: cognition, locomotion, nutrition, sensory and psychological. However, little is known about the integration of the domains.

OBJECTIVES

to investigate patterns in the presentation and evolution of IC domain impairments in low-and-middle-income countries and if such patterns were associated with adverse outcomes.

METHODS

secondary analyses of the first two waves of the 10/66 study (population-based surveys conducted in eight urban and four rural catchment areas in Cuba, Dominican Republic, Puerto Rico, Venezuela, Peru, Mexico and China). We applied latent transition analysis on IC to find latent statuses (latent clusters) of IC domain impairments. We evaluated the longitudinal association of the latent statuses with the risk of frailty, disability and mortality, and tested concurrent and predictive validity.

RESULTS

amongst 14,923 participants included, the four latent statuses were: high IC (43%), low deterioration with impaired locomotion (17%), high deterioration without cognitive impairment (22%), and high deterioration with cognitive impairment (18%). A total of 61% of the participants worsened over time, 35% were stable, and 3% improved to a healthier status.Participants with deteriorated IC had a significantly higher risk of frailty, disability and dementia than people with high IC. There was strong concurrent and predictive validity. (Mortality Hazard Ratio = 4.60, 95%CI 4.16; 5.09; Harrel's C = 0.73 (95%CI 0.72;0.74)).

CONCLUSIONS

half of the study population had high IC at baseline, and most participants followed a worsening trend. Four qualitatively different IC statuses or statuses were characterised by low and high levels of deterioration associated with their risk of disability and frailty. Locomotion and cognition impairments showed other trends than psychological and nutrition domains across the latent statuses.

Cardiovascular Complications in Patients Hospitalized for COVID-19: A Cohort Study in Havana, Cuba

INTRODUCTION AND OBJECTIVE

At least one in ten patients infected with COVID develop cardiovascular complications during hospitalization, increasing the number of deaths from this cause. However, the determinants of risk are not clearly elucidated. This study aims to determine whether there is a relationship between in-hospital cardiac complications and cardiovascular history and hospital evolution.

METHODS

Prospective cohort study of 373 patients with a positive diagnosis of SARS-CoV-2 admitted to an Intensive Care Unit between March and October 2021.

RESULTS

Median age was 69 (IQR: 57-77), 29.2 % of patients presented cardiovascular complications: 21.2 % electrical, 5.9 % acute coronary syndrome and 1.9 % pulmonary thromboembolism. Age RR: 1.02 (95 % CI: 1.00-1.04; p = 0.020) and history of ischemic heart disease RR: 2.23 (95 % CI: 1.27-3.92; p = 0.005) were identified as independent predictors of in-hospital cardiac complications.

CONCLUSIONS

Age and history of ischemic heart disease were identified as independent predictor variables of cardiovascular complications in patients admitted with severe COVID-19 involvement; being significantly associated with lower survival.

Prevalence of Anemia and Iron Deficiency in Women of Reproductive Age in Cuba and Associated Factors

This study aims to evaluate the prevalence of anemia and iron deficiency in women of reproductive age and the association with inflammation, global overweight, adiposity, and menorrhagia. A sample design of women of reproductive age from the Eastern, Central, and Havana Regions was carried out. Biochemical determinations of hemoglobin, serum ferritin, soluble transferrin receptors, leukocytes, C-reactive protein, alpha-1 acid glycoprotein, and homocysteine were performed. Serum ferritin was also adjusted by inflammation. Nutritional status was assessed, and menstrual characteristics were collected by survey. A total of 742 women were studied. The prevalence of anemia was 21.4%, iron storage deficiency at 16.0%, and erythropoietic dysfunction at 5.4%, with inflammation at 47.0% and elevated homocysteine at 18.6%. Global overweight was 46.2% and increased adiposity at 58.4%. Anemia is associated with iron deposition deficiency (OR = 3.023 (1.816-5.033)) and with erythropoietic deficiency (OR = 5.62 (3.03-10.39)), but not with inflammation, global overweight, and adiposity. Global overweight was found to be associated with inflammation (OR = 2.23 (1.41-3.53)). Anemia was associated with heavy menstrual bleeding (OR = 1.92 (1.34-2.76)). Homocysteine was associated with inflammation (OR = 2.05 (1.08-3.90)), but not with anemia. In conclusion, anemia in Cuba is classified as a moderate public health problem, but not iron deficiency. A high prevalence of overweight and obesity was found, associated with inflammation, but not with anemia or iron deficiency. Heavy menstrual bleeding is a factor associated with anemia.

Prevalence of Alzheimer's disease in rural and urban areas in Cuba and factors influencing on its occurrence: epidemiological cross-sectional protocol

INTRODUCTION

According to the World Alzheimer's Report 2019, around 50 million people suffer from dementia, worldwide. Observational analysis revealed the existence of particular factors associated with the onset and progression of Alzheimer's disease (AD). There are no international homogeneous principles for the early detection and evaluation of memory impairment and possible AD. This work aimed at (1) determining the prevalence of possible AD in the elderly residing in urban and rural regions in Cuba and (2) identifying the main factors that could significantly influence on its occurrence.

METHODS AND ANALYSIS

The study includes four neuropsychological tests (Clock Drawing Test, Mini-Mental Status Examination, Short Portable Mental Status Questionnaire, Cognitive and Non-Cognitive Alzheimer's Disease Assessment Scale) and two scales (Clinical Dementia Rating and Global Deterioration Scale). Moreover, the protocol includes a survey with demographic and socioeconomic information, educational level, occupation, health, neuropsychological status of subjects, familial pathological history, comorbidities and lifestyles. The study will comprise a total of 1092 subjects aged ≥60, of both genders, and from every ethnic group settled in rural and urban areas.

PRIMARY OUTCOMES

prevalence of possible AD.

SECONDARY OUTCOMES

correlation among risk and protective factors and AD, and comparison of the performance of neuropsychological tests and scales.

ETHICS AND DISSEMINATION

This research met the ethical codes of the Declaration of Helsinki. The Scientific Research Council of the Promoting Research Institute and the Ethics Committee of the Health Authorities approved the protocol. The proper written informed consent is also incorporated. The results of the survey will be published in scientific papers and shared with the Health Authorities of each municipality.

Educational inequalities and premature mortality: the Cuba Prospective Study

BACKGROUND

Although socioeconomic status is a major determinant of premature mortality in many populations, the impact of social inequalities on premature mortality in Cuba, a country with universal education and health care, remains unclear. We aimed to assess the association between educational level and premature adult mortality in Cuba.

METHODS

The Cuba Prospective Study (a cohort study) enrolled 146 556 adults aged 30 years and older from the general population in five provinces from Jan 1, 1996, to Nov 24, 2002. Participants were followed up until Jan 1, 2017, for cause-specific mortality. Deaths were identified through linkage to the Cuban Public Health Ministry's national mortality records. Cox regression models yielded rate ratios (RRs) for the effect of educational level (a commonly used measure for social status) on mortality at ages 35-74 years, with assessment for the mediating effects of smoking, alcohol consumption, and BMI.

FINDINGS

A total of 127 273 participants aged 35-74 years were included in the analyses. There was a strong inverse association between educational level and premature mortality. Compared with a university education, men who did not complete primary education had an approximately 60% higher risk of premature mortality (RR 1·55, 95% CI 1·40-1·72), while the risk was approximately doubled in women (1·96, 1·81-2·13). Overall, 28% of premature deaths could be attributed to lower education levels. Excess mortality in women was primarily due to vascular disease, while vascular disease and cancer were equally important in men. 31% of the association with education in men and 18% in women could be explained by common modifiable risk factors, with smoking having the largest effect.

INTERPRETATION

This study highlights the value of understanding the determinants of health inequalities in different populations. Although many major determinants lie outside the health system in Cuba, this study has identified the diseases and risk factors that require targeted public health interventions, particularly smoking.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, CDC Foundation (with support from Amgen).

Prevalence, Incidence, and Persistence of Postpartum Anxiety, Depression, and Comorbidity: A Cohort Study Among Women in Havana Cuba

OBJECTIVE

To estimate the prevalence, incidence, and persistence of postpartum anxiety, depression, and comorbid symptoms over the first 6 months postpartum in a cohort of Havana women and to evaluate the sensitivity, specificity, and predictive power of the Edinburgh Postnatal Depression Scale (EPDS) and the State-Trait Anxiety Inventory (STAI) at 4 weeks postpartum on depressive and anxiety symptoms at 12 and 24 weeks.

METHOD

A cohort study with 273 women in Havana, Cuba. Participants were assessed at 4, 12, and 24 weeks postpartum for anxiety, depression, and comorbid symptoms.

RESULTS

Prevalence rates were highest at 4 weeks postpartum: 20.0% women reported elevated levels of anxiety and 16.4% reported depressive symptoms. The prevalence of comorbid anxiety and depression was 5.8%. While rates of anxiety steadily decreased to 13.8% at 24 weeks, rates of depression persisted to 24 weeks postpartum with 14.5% still experiencing elevated symptoms. Comorbid anxiety and depression decreased across time. There were limited sensitivity and poor predictive values for both the STAI and the EPDS.

CONCLUSION

This study is the first to examine perinatal mental illness in Cuba. While anxiety and depression rates found among Cuban women are lower than those reported in other low-income countries, the rates paralleled high-income countries.

Comparing the COVID-19 Responses in Cuba and the United States

The purpose of this analytic essay is to contrast the COVID-19 responses in Cuba and the United States, and to understand the differences in outcomes between the 2 nations. With fundamental differences in health systems structure and organization, as well as in political philosophy and culture, it is not surprising that there are major differences in outcomes. The more coordinated, comprehensive response to COVID-19 in Cuba has resulted in significantly better outcomes compared with the United States. Through July 15, 2021, the US cumulative case rate is more than 4 times higher than Cuba's, while the death rate and excess death rate are both approximately 12 times higher in the United States. In addition to the large differences in cumulative case and death rates between United States and Cuba, the COVID-19 pandemic has unmasked serious underlying health inequities in the United States. The vaccine rollout presents its own set of challenges for both countries, and future studies can examine the comparative successes to identify effective strategies for distribution and administration. (Am J Public Health. 2021;111(12):2186-2193. https://doi.org/10.2105/AJPH.2021.306526).

Test positivity - Evaluation of a new metric to assess epidemic dispersal mediated by non-symptomatic cases

Epidemic control may be hampered when the percentage of asymptomatic cases is high. Seeking remedies for this problem, test positivity was explored between the first 60 to 90 epidemic days in six countries that reported their first COVID-19 case between February and March 2020: Argentina, Bolivia, Chile, Cuba, Mexico, and Uruguay. Test positivity (TP) is the percentage of test-positive individuals reported on a given day out of all individuals tested the same day. To generate both country-specific and multi-country information, this study was implemented in two stages. First, the epidemiologic data of the country infected last (Uruguay) were analyzed. If at least one TP-related analysis yielded a statistically significant relationship, later assessments would investigate the six countries. The Uruguayan data indicated (i) a positive correlation between daily TP and daily new cases (r = 0.75); (ii) a negative correlation between TP and the number of tests conducted per million inhabitants (TPMI, r = -0.66); and (iii) three temporal stages, which differed from one another in both TP and TPMI medians (p < 0.01) and, together, revealed a negative relationship between TPMI and TP. No significant relationship was found between TP and the number of active or recovered patients. The six countries showed a positive correlation between TP and the number of deaths/million inhabitants (DMI, r = 0.65, p < 0.01). With one exception -a country where isolation was not pursued-, all countries showed a negative correlation between TP and TPMI (r = 0.74). The temporal analysis of country-specific policies revealed four patterns, characterized by: (1) low TPMI and high DMI, (2) high TPMI and low DMI; (3) an intermediate pattern, and (4) high TPMI and high DMI. Findings support the hypothesis that test positivity may guide epidemiologic policy-making, provided that policy-related factors are considered and high-resolution geographical data are utilized.

[Covid-19 in Cuba, six months later]

Cuba has a long tradition of controlling epidemics. In Cuba, this occurred with covid-19 six months after it started. Different measures were taken to control the pandemic: various community interventions, the isolation of suspected cases and of people returning from overseas, the application of therapeutic strategies. The first phase of the epidemic peaked in late April and the highest number of cases was seen in May. The epidemic was under control in June and July. Cases began to de-escalate in mid-June. There was a rise in cases in the month of August, which was interpreted as another outbreak.

Leprosy in children in Cuba: Epidemiological and clinical description of 50 cases from 2012-2019

INTRODUCTION

In 1993, Cuba achieved leprosy elimination according to the World Health Organization's (WHO) indicator of less than one case per 10,000 population. Despite this achievement, detection of new cases occurs every year among all age groups including children. Detection of new cases in children reveals persistent transmission of the infection.

OBJECTIVE

To describe the clinical and epidemiological features of leprosy in individuals younger than 15 years (childhood leprosy) reported to the Cuban National Leprosy Control Program (NLCP) between 2012 and 2019.

METHODS

We conducted a retrospective descriptive study between 2012 and 2019 to assess the clinical and epidemiologic features of individuals under the age of 15 years with a confirmed diagnosis of leprosy reported to the NLCP. We reviewed the NLCP database and collected data to better define the total number of cases of leprosy in adults, children (younger than 15 years). We assessed socio-demographic variables (age, gender, and province of residence) as well as variables of clinical interest including operational classification and staging at diagnosis, bacillary index, grade of disability by WHO staging. Additionally, we evaluated epidemiological variables including passive versus active surveillance of cases, contact investigation focusing specifically in household transmission, and the degree of kinship as well as standing of the child within the focus of transmission when there were additional cases.

RESULTS

We identified fifty children during the study period corresponding to 3% of the overall cases of leprosy comprising all age groups in Cuba. In the age group younger than 15 years, the majorities of cases was from the Granma province and most were between the ages of 10 and 14 years. Clinically, multibacillary/lepromatous forms were the most common type identified with positive bacillary index. The majority of children diagnosed with leprosy during our study period had a history of a relative with a confirmed diagnosis of leprosy.

CONCLUSIONS

Detection of cases of leprosy in individuals younger than 15 years of age in Cuba demonstrates ongoing transmission of M. leprae in specific geographic hotspots. Its frequency in the early adolescence, the predominant clinical forms, and the mode of detection associated with sources of suspected familiar infection demonstrated that there is a need for further efforts by the NLCP to conduct active surveillance activities among affected communities to identify cases of leprosy earlier with the goal of preventing further household and community transmission.

COVID-19 contagion concern scale (PRE-COVID-19): Validation in Cuban patients with type 2 diabetes

AIMS

It is important to have valid and reliable measures to determine the psychological impact of COVID-19 in patients with diabetes; however, few instruments have been developed and validated for this population. Therefore, the aim of this study was to validate the Scale of Worry for Contagion of COVID-19 (PRE-COVID-19) in a sample of patients with diabetes mellitus (DM).

MATERIALS AND METHODS

A total of 219 patients (66.2% female, mean age 58.5 SD = 18.2) participated, selected through non-probabilistic sampling. The PRE-COVID-19 and the Generalized Anxiety Disorder Scale-2 were applied. Reliability analysis was performed for internal consistency, structural equation modeling and item response theory modeling.

RESULTS

The results show that a unidimensional 5-item model presents satisfactory goodness-of-fit indices and excellent reliability values. Likewise, convergent validity between the PRE-COVID-19 and a measure of anxiety is evident. All items present adequate discrimination parameters, allowing for discerning between those patients with critical concern about COVID-19 contagion from those with severe concern.

CONCLUSION

It is concluded that the PRE-COVID-19 is an instrument with adequate psychometric properties to measure concern about COVID-19 infection and the emotional impact in patients with DM.

Cuban history of CRF19 recombinant subtype of HIV-1

CRF19 is a recombinant form of HIV-1 subtypes D, A1 and G, which was first sampled in Cuba in 1999, but was already present there in 1980s. CRF19 was reported almost uniquely in Cuba, where it accounts for ∼25% of new HIV-positive patients and causes rapid progression to AIDS (∼3 years). We analyzed a large data set comprising ∼350 pol and env sequences sampled in Cuba over the last 15 years and ∼350 from Los Alamos database. This data set contained both CRF19 (∼315), and A1, D and G sequences. We performed and combined analyses for the three A1, G and D regions, using fast maximum likelihood approaches, including: (1) phylogeny reconstruction, (2) spatio-temporal analysis of the virus spread, and ancestral character reconstruction for (3) transmission mode and (4) drug resistance mutations (DRMs). We verified these results with a Bayesian approach. This allowed us to acquire new insights on the CRF19 origin and transmission patterns. We showed that CRF19 recombined between 1966 and 1977, most likely in Cuban community stationed in Congo region. We further investigated CRF19 spread on the Cuban province level, and discovered that the epidemic started in 1970s, most probably in Villa Clara, that it was at first carried by heterosexual transmissions, and then quickly spread in the 1980s within the "men having sex with men" (MSM) community, with multiple transmissions back to heterosexuals. The analysis of the transmission patterns of common DRMs found very few resistance transmission clusters. Our results show a very early introduction of CRF19 in Cuba, which could explain its local epidemiological success. Ignited by a major founder event, the epidemic then followed a similar pattern as other subtypes and CRFs in Cuba. The reason for the short time to AIDS remains to be understood and requires specific surveillance, in Cuba and elsewhere.

Molecular detection and identification of spotted fever group rickettsiae in ticks collected from horses in Cuba

Spotted fever group (SFG) rickettsiae are obligatory intracellular bacteria that cause disease in humans and other animals. Ixodid ticks are the principal vectors of SFG rickettsiae. The present study aimed to determine the prevalence and species identity of SFG rickettsiae in ticks and horses from urban and rural areas of western Cuba using PCR assays. Tick samples, collected from 79 horses, consisted of 14 Amblyomma mixtum adults, 111 Dermacentor nitens adults and 19 pools of D. nitens nymphs (2-5 individuals/pool). The PCR results revealed the presence of Rickettsia spp. in 64% of the A. mixtum adults, 16% of the D. nitens adults, and 11% of the pooled samples of D. nitens nymphs. In contrast, Rickettsia spp. was not detected in any of the 200 horse blood samples included in this study. DNA sequence data of the rickettsial 17 kDa antigen gene showed that Rickettsia amblyommatis was present in A. mixtum; and Rickettsia felis in D. nitens. This is the first report of R. felis in D. nitens in Cuba. The present study extends our knowledge of the potential vector spectrum and distribution of SFG rickettsiae pathogens in western Cuba.

Body-mass index, blood pressure, diabetes and cardiovascular mortality in Cuba: prospective study of 146,556 participants

BACKGROUND

Cardiovascular disease accounts for about one-third of all premature deaths (ie, age < 70) in Cuba. Yet, the relevance of major risk factors, including systolic blood pressure (SBP), diabetes, and body-mass index (BMI), to cardiovascular mortality in this population remains unclear.

METHODS

In 1996-2002, 146,556 adults were recruited from the general population in five areas of Cuba. Participants were interviewed, measured (height, weight and blood pressure) and followed up by electronic linkage to national death registries until Jan 1, 2017; in 2006-08, 24,345 participants were resurveyed. After excluding all with missing data, cardiovascular disease at recruitment, and those who died in the first 5 years, Cox regression (adjusted for age, sex, education, smoking, alcohol and, where appropriate, BMI) was used to relate cardiovascular mortality rate ratios (RRs) at ages 35-79 years to SBP, diabetes and BMI; RR were corrected for regression dilution to give associations with long-term average (ie, 'usual') levels of SBP and BMI.

RESULTS

After exclusions, there were 125,939 participants (mean age 53 [SD12]; 55% women). Mean SBP was 124 mmHg (SD15), 5% had diabetes, and mean BMI was 24.2 kg/m2 (SD3.6); mean SBP and diabetes prevalence at recruitment were both strongly related to BMI. During follow-up, there were 4112 cardiovascular deaths (2032 ischaemic heart disease, 832 stroke, and 1248 other). Cardiovascular mortality was positively associated with SBP (>=120 mmHg), diabetes, and BMI (>=22.5 kg/m2): 20 mmHg higher usual SBP about doubled cardiovascular mortality (RR 2.02, 95%CI 1.88-2.18]), as did diabetes (2.15, 1.95-2.37), and 10 kg/m2 higher usual BMI (1.92, 1.64-2.25). RR were similar in men and in women. The association with BMI and cardiovascular mortality was almost completely attenuated following adjustment for the mediating effect of SBP. Elevated SBP (>=120 mmHg), diabetes and raised BMI (>=22.5 kg/m2) accounted for 27%, 14%, and 16% of cardiovascular deaths, respectively.

CONCLUSIONS

This large prospective study provides direct evidence for the effects of these major risk factors on cardiovascular mortality in Cuba. Despite comparatively low levels of these risk factors by international standards, the strength of their association with cardiovascular death means they nevertheless exert a substantial impact on premature mortality in Cuba.

COVID-19 Requires Innovation, Regulation and Rigor: Amaylid Arteaga-García MD MS Director, National Clinical Trials Coordinating Center (CENCEC)

The effects and implications of COVID-19 are global, comprehensive and long-term. The pandemic has exposed inequities, the fragility of economic and political systems, and in many cases, skewed priorities. Population health, not to mention planetary health, is suffering as a result. Nevertheless, the global health crisis in which we are embroiled has provided opportunities for effective collaboration, scientific innovation and real dialog around health and equity. Dr Amaylid Arteaga-García, director of Cuba's National Clinical Trials Coordinating Center (CENCEC), emphasized these opportunities when discussing Cuba's clinical trials in times of COVID-19. Founded in 1991 in response to the groundbreaking research emerging from the country's biopharmaceutical sector-including the first safe, effective vaccine against serogroup B meningococcal disease, VA-MENGOC-BC in 1989 and a recombinant vaccine against hepatitis B, Heberbiovac in 1990-CENCEC now coordinates some 100 clinical trials annually, many of them multi-site trials involving thousands of volunteers. Little did Dr Arteaga García know what problems lurked when she became CENCEC director in 2019. In February 2020, Cuba implemented its National COVID-19 Prevention & Control Plan. This included a scientific Innovation Committee tasked with evaluating promising projects, products and research that might be used in the health system to control and treat COVID-19. This approach taps into two of Cuba's strengths: biotechnology and primary health care. Given the volume and complexity of COVID-19 clinical trials, Dr Arteaga.

Monoclonal Antibodies vs COVID-19: Eduardo Ojito-Magaz MS General Director, Molecular Immunology Center

Cuba has five COVID-19 vaccines in clinical trials and is on track to receive emergency use authorization from the country's regulatory agency to begin mass vaccination with two of those candidates: Abdala and SOBERANA 02. Results from phase 1 and 2 trials of these vaccines, the first developed and produced in Latin America, have been encouraging, both in terms of safety and immunogenicity. The ongoing phase 3 trials will continue to look at safety, together with efficacy; parallel intervention studies involving over a million people in Havana will begin generating data on effectiveness. Coordination between Cuba's biotechnology sector and its public health system-particularly throughout the different levels of primary care-to control and treat COVID-19 is a cornerstone of the Cuban strategy and one that could serve as a blueprint for future pandemics. Another Cuban product, itolizumab, is showing positive results mitigating cytokine release syndrome (CRS) in COVID-19 patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Developed in collaboration with Biocon (India), itolizumab is administered under an expanded access program to treat vulnerable populations in Cuba. Marshaling complementary capacities of dozens of institutions belonging to BioCubaFarma-the country's biotech conglomerate-and developing therapies, vaccines and medical technologies together, is another cornerstone of Cuba's strategy to combat COVID-19 and improve population health. The Molecular Immunology Center (CIM) is a key player in this strategy. Founded in 1992, CIM is a powerhouse in monoclonal antibody research and production, with 6 registered products and 22 in the pipeline. Known for several novel therapeutic cancer treatments, CIM has over two decades' experience producing complex recombinant proteins in mammalian cells on an industrial scale. Once Cuba's Innovation Committee (convened in January 2020 as part of the National COVID-19 Prevention & Control Plan) determined Cuban researchers would pursue protein subunit vaccine candidates, they turned to CIM to produce the required receptor-binding domain (RBD) of the SARS-CoV-2 spike protein, among other responsibilities. CIM's General Director, Dr Eduardo Ojito-Magaz, is a chemical engineer and holds a master's degree in biotechnology. He spoke with MEDICC Review just days before 1.7 million Havana residents began participating in the country's largest intervention study with the COVID-19 vaccines his center helped make possible.

VA-MENGOC-BC Vaccination Induces Serum and Mucosal Anti Neisseria gonorrhoeae Immune Responses and Reduces the Incidence of Gonorrhea

BACKGROUND

Overall, there are over 30 different sexually transmitted infections with Neisseria gonorrhoeae being the third most frequent with a reported 78 million cases per year. Gonococcal infection causes genital inflammation, which can be a risk factor for others sexually transmitted infections, particularly human immunodeficiency virus. Gonorrhea is a treatable disease, but recently an increase in antibiotic resistance has been of concern. There are currently no vaccines available. However, parenteral vaccination with anti N. meningitidis serogroup B vaccine has been reported to decrease the incidence of gonococcal burden in New Zealand and in Cuba despite the fact that parenteral vaccination is not deemed to induce mucosal IgA. Here we explore possible mechanisms of protection against gonococcal infection through parenteral meningococcal B vaccination.

METHODS

Ninety-two serum, saliva and oropharyngeal swabs samples of young adults (healthy and Neisseria carriers) of the internal higher school were obtained. They have been vaccinated with VA-MENGOC-BC (MBV) during their infancy and boosted with a third dose during this study. Serum and saliva samples were analyzed by ELISA and Western blot to measured IgG and IgA antibodies against N. meningitidis and N. gonorrhoeae antigens. N. meningitidis carriers were determined by standard microbiologic test. In addition, we reviewed epidemiologic data for N. meningitidis and N. gonorrhoeae infections in Cuba.

RESULTS

Epidemiologic data show the influence of MBV over gonorrhea incidence suggesting to be dependent of sexual arrival age of vaccines but not over syphilis. Laboratorial data permit the detection of 70 and 22 noncarriers and carriers of N. meningitidis, respectively. Serum anti-MBV antigens (PL) responses were boosted by a third dose and were independent of carriage stages, but saliva anti-PL IgA responses were only present and were significant induced in carriers subjects. Carriers boosted with a third dose of MBV induced similar antigonococcal and -PL saliva IgA and serum IgG responses; meanwhile, serum antigonococcal IgG was significantly lower. In saliva, at least 2 gonococcal antigens were identified by Western blot. Finally, gonococcal-specific mucosal IgA antibody responses, in addition to the serum IgG antibodies, might contributed to the reduction of the incidence of N. gonorrhoeae. We hypothesize that this might have contributed to the observed reductions of the incidence of N. gonorrhoeae.

CONCLUSION

These results suggest a mechanism for the influence of a Proteoliposome-based meningococcal BC vaccine on gonococcal incidence.

Circulation of Human Papillomavirus and Chlamydia trachomatisin Cuban Women

INTRODUCTION Human papillomaviruses and Chlamydia tracho-matis are the most frequent causes of sexually transmitted infec-tions. Although the association between some human papillomavirus genotypes and cervical cancer has been demonstrated and Chla-mydia trachomatis infection is the most common cause of female infertility, Cuba has no national baseline studies on the circulation and co-circulation of these agents, the synergistic effect of which may be a risk factor for occurrence and development of precancer-ous cervical lesions. Additionally, few local studies have examined risk factors for infection.OBJECTIVE Determine the frequency of infection by human papil-lomavirus and Chlamydia trachomatis and their association with sociodemographic, clinical and epidemiological variables in women seeking routine Pap smears or other medical services at the primary care level in Cuba.METHODS A cross-sectional study was conducted among 500 wom-en aged 16-67 years (100 from Havana, 200 from Villa Clara and 200 from Holguín Provinces, Cuba), from August through December 2015. Chlamydia trachomatis infection was detected by real-time polymerase chain reaction and 35 genotypes of human papillomavirus by low-density microarray. We then examined the association of infec-tion with sociodemographic, clinical and epidemiological variables.RESULTS Human papillomavirus was detected in 14.8% (74/500) of the women. Of the 29 genotypes identifi ed, 79.7% (59/74) were onco-genic high-risk types. Type 16 was the most frequently identifi ed (23%; 17/74), followed by type 31 (10.8%; 8/74) and then by types 33, 53, 61 and 66 in equal proportions (8.1%; 6/74). Infection frequency was greater in women aged ≤25 years (38.8%; 31/80), students (46.7% 7/15), single women (23.0%; 40/174) and among those who reported having more than 3 sexual partners in the last 2 years (41.5%; 17/41). Differences were found among provinces for circulating genotypes and infection-related variables. Human papillomavirus infection from genotypes 16, 31, 33, 53, 61, 66, 68 and 89 was associated with the 7.9% (30/382) of women who had positive Pap tests. Infection fromChlamydia trachomatis was positive in 1% (5/500) of women, all aged ≤25 years. Coinfection by Chlamydia trachomatis and HPV was found in one woman infected with human papillomavirus genotype 61.CONCLUSIONS Frequency of human papillomavirus is high in the three Cuban provinces studied, with greater frequency of genotype 16 and other oncogenic high-risk types. For both agents, infection is more frequent in young women and adolescents. Positive Pap tests are fre-quently associated with HPV infection. Prevalence fi ndings from this study could be used as a baseline for future research or interventions. KEYWORDS Human papillomavirus, genotypes, Chlamydia tracho-matis, neoplasms, sexually transmitted diseases, cervix Uteri, infec-tion, real-time polymerase chain reaction, women, Cuba.

Researchers at Cuba's National Medical Genetics Center: Pioneering Studies on COVID-19

Three fourths of the 175 staff at Cuba's National Medical Genetics Center (CNGM) are women. And women constitute 90% of the research team working on the Center's largest current project-unlocking the biological secrets of COVID-19 in the Cuban population. They are identifying particularly vulnerable groups and geographies, reviewing therapies applied and long-term sequelae of the disease, and contributing to ongoing vaccine research and trials. Their results are critical to determining effective preventive and treatment strategies as the country moves into the next phases of epidemic control. The national study is the first and only one of its kind in Latin America. Then the first COVID-19 cases were diagnosed in Cuba on March 11, 2020, the Center's role in epidemiological surveillance was activated, based on its experience with the Zika threat in 2015. This involved mobilizing the National Genetics Network anchored in primary healthcare facilities, comprised of 452 genetics counselors, nurses and clinical geneticists, supported by technicians, epidemiologists and family doctors. The Network's role would become key to the ensuing research. As the magnitude of the pandemic became clearer, CNGM investigators approached the Ministry of Public Health and government leaders with a broad-ranging proposal to study biological factors that would help explain differences in vulnerability, symptoms, immune response and severity of the disease, as well as its profile in different Cuban subpopulations. After approval, the studies got underway in June, encompassing Cubans who had been infected through June 11, 2020, and were by now convalescing. The nine main research lines were defined, and principal investigators went to work developing the instruments needed and training personnel across the island on their use. While final results are still being analyzed, CNGM Director Dr Beatriz Marcheco and four lead researchers talked with MEDICC Review about the scope of their work and some of the most intriguing preliminary findings.

COVID-19 in Cuba: Assessing the National Response

The COVID-19 pandemic exhibits different characteristics in each country, related to the extent of SARS-CoV-2 local transmission, as well as the speed and effectiveness of epidemic response implemented by authorities. This study presents a descriptive epidemiological analysis of the daily and cumulative incidence of confi rmed cases and deaths in Cuba from COVID-19 in the fi rst 110 days after fi rst-case confi rmation on March 11, 2020. During this period, 2340 cases (20.7 x 100,000 population) were confi rmed, of which 86 patients died (case fatality 3.67%; 52 men and 34 women). Mean age of the deceased was 73.6 years (with a minimum of 35 years and a maximum of 101), with the average age of men lower than that of women. More than 70% of all deceased had associated noncommunicable diseases. The incidence curve ascended for fi ve weeks and then descended steadily. The average number of confi rmed cases and deaths for the last week included (June 23-28, 2020) were 25 and 1 respectively; the curve always moved within the most favorable forecast zone of available mathematical models and the effective reproductive number fell below 1 after the fi fth week following the onset of the epidemic.

SOBERANA, Cuba's COVID-19 Vaccine Candidates: Dagmar García-Rivera PhD

On August 13, 2020, Cuba's national regulatory agency, the Center for Quality Control of Medicines, Equipment and Medical Devices (CECMED), authorized clinical trials for SOBERANA 01-Cuba's fi rst vaccine candidate and the fi rst from Latin America and the Caribbean. On August 24, parallel Phase I/II double blind, randomized, controlled clinical trials were launched at clinical sites in Havana to evaluate the vaccine's safety and immunogenicity. Analysis of results and development of different formulations are currently under way and Phase III clinical trials are planned for early 2021. At the time of writing, a second vaccine candidate, SOBERANA 02, was in late-stage development and preparing to begin separate trials this fall.

Early Action, Applied Research & Collaboration to Combat COVID-19: María Guadalupe Guzmán MD PhD DSc

Virologist Dr María Guadalupe Guzmán is recognized as a global leader in dengue research and heads the Pedro Kourí Tropical Medicine Institute's work as a WHO/PAHO Collaborating Center for the Study of Dengue and Its Vector. The Institute (IPK) was founded in 1937 and is now Cuba's national reference center for the diagnosis, treatment, control and prevention of communicable diseases. Dr Guzmán is also president of the Cuban Society of Microbiology and Parasitology and directs IPK's Scientifi c Council, which is responsible for setting the Institute's research priorities. A recent h-index analysis found that Dr Guzmán is among the most widelypublished and cited Cuban researchers.

COVID-19 and the Rocket Science of Public Health

We are all fatigued, frazzled. Many of us have lost too many and too much, and still more will suffer long-term physical and mental effects. A strange geography has cropped into our lexicon: states, provinces and entire countries mapped by their rates of COVID-19, telling us how dangerous it is to go outside, go to work or school. It is also the geography of health care, leadership and policies that aim to protect people fi rst-or not-the willingness to embrace the simply brilliant and brilliantly simple lessons of public health.

A PAHO Perspective on COVID-19 in Cuba José Moya MD MPH PhD

If all physicians are detectives, using their skills to track down what ails body and mind, then epidemiologists are medicine's social detectives, using their training to understand the great calamities of population health. For over 30 years, Dr José Moya has worked in the fi eld since his initial position as head of epidemiology in Ayacucho, in his home country of Peru. His journey into global health began with Doctors Without Borders in Guatemala, Mozambique and Nigeria. Later at PAHO, he was Permanent Representative in Venezuela, after earlier postings as an epidemiologist in Haiti, Mexico, Brazil, the Dominican Republic and Argentina.

Characterization of Deaths from Cirrhosis of the Liver in Cuba, 1987-2017

INTRODUCTION Cirrhosis of the liver is a chronic disease that is widespread and irreversible. It represents the fi nal stage of numerous diseases that affect the liver. By the end of 2017, it was the 11th most common cause of death, with a loss of 41.4 million years of disability-adjusted life years, which represent 2.1% of the total years of life lost in the global mortality burden. In Cuba, cirrhosis and other chronic liver diseases have been among the top 10 causes of death for several decades, their rates consistently increasing, from 576 deaths in 1970 (6.7 per 100,000 population) to 1738 in 2017 (15.5 per 100,000 population), with a risk of death that is 4.6 times higher in men. OBJECTIVE Characterize deaths from cirrhosis of the liver in Cuba from 1987 to 2017. METHODS An ecological time-series study was conducted for 1987 to 2017 using information obtained from the mortality database of the Medical Records and Health Statistics Bureau of Cuba's Ministry of Public Health. The study universe consisted of all deceased persons in the country whose underlying cause of death was cirrhosis of the liver. Both general mortality rates and specifi c mortality were calculated by age group, sex and etiological classifi cation using adjusted and crude rates. Rates were age-adjusted using the direct method, and the population from the 2002 Census of Population and Housing was considered as the standard population. Percentages and means were also calculated according to selected variables and the relative risk of death due to the disease according to sex, age group and etiological classifi cation. The trend and forecast for mortality rates were estimated for this disease. RESULTS The crude mortality rate from cirrhosis of the liver was 9.0 per 100,000 population for the period. Those aged ≥75 years had the highest risk of death (48.3 per 100,000 population). The crude and adjusted mortality rates were almost double for men (12.4 vs. 5.6 and 11.7 vs. 5.6 per 100,000 population, respectively), as was the total relative risk of death, which was 2.2 times higher. Nonalcoholic cirrhosis accounted for 71.6% of deaths. By the end of 2017, risk of death from cirrhosis had climbed to 14.8 per 100,000 population (adjusted rate: 10.6 per 100,000 population), a signal that mortality had progressively increased over the 31 years analyzed. In addition, forecasts predict that death rates will continue their gradual increase, reaching 19.2 per 100,000 population in 2025. CONCLUSIONS Deaths from cirrhosis of the liver constitute a substantial health burden in Cuba. The upward trend and forecast, in addition to increased risk of mortality in men and older adults, are similar to those reported internationally. The fi nding that most of these deaths result from nonalcoholic cirrhosis should be further studied, as formulation of effective public health strategies depends largely on attaining a better understanding of the etiology, progression and social determinants of the disease. KEYWORDS Liver cirrhosis, alcoholic liver cirrhosis, fatty liver, mortality, Cuba.

Fallen in the Face of COVID-19: Graduates of Cuba's Latin American School of Medicine (ELAM)

The 2020 fall semester at Havana's Latin American School of Medicine (ELAM) began on an especially somber note: honoring 17 of its alumni felled as they battled COVID-19 in their home countries and beyond. A few were recent graduates among the 30,047 from 118 countries who received scholarships from Cuba to study medicine at ELAM. Others were members of its fi rst graduating class in 2005.

Not Infected but Physically and Mentally Affected: Older Cubans and COVID-19

COVID-19 has dominated the conversation this year. Following the fi rst outbreaks in December 2019, it became clear that older adults were predisposed to greater disease severity and death. What occurred in nursing homes across Europe and the Americas was brutal-as much for the older adults themselves as for their families. Many didn't even get to say goodbye.

Factors related with sarcopenia and sarcopenic obesity among low- and middle-income settings: the 10/66 DRG study

Sarcopenia and sarcopenic obesity research in low- and middle- income countries (LMICs) is limited. We investigated sarcopenia and sarcopenic obesity prevalence and sociodemographic, bio-clinical and lifestyle factors in LMICs settings. For the purposes of this study, the 10/66 Dementia Research Group follow-up wave information from individuals aged 65 and over in Cuba, Dominican Republic, Peru, Mexico, Puerto Rico, China, was employed and analysed (n = 8.694). Based on indirect population formulas, we calculated body fat percentage (%BF) and skeletal muscle mass index (SMI). Sarcopenia prevalence ranged from 12.4% (Dominican Republic) to 24.6% (rural Peru); sarcopenic obesity prevalence ranged from 3.0% (rural China) to 10.2% (rural Peru). Odds ratios (OR) with 95% confidence intervals (CI) for sarcopenia were higher for men 2.82 (2.22-3.57) and those with higher %BF 1.08 (1.07-1.09), whereas higher number of assets was associated with a decreased likelihood 0.93 (0.87-1.00). OR of sarcopenic obesity were higher for men 2.17 (1.70-2.76), those reporting moderate alcohol drinking 1.76 (1.21-2.57), and those with increased number of limiting impairments 1.54 (1.11-2.14). We observed heterogeneity in the prevalence of sarcopenia and sarcopenic obesity in the 10/66 settings. We also found a variety of factors to be associated with those. Our results reveal the need for more research among the older population of LMICs.

Sickle Cell Anemia in Cuba: Prevention and Management, 1982-2018

Sickle cell anemia is the most common hereditary disease in Cuba. On average, 1 in 33 Cubans is a carrier of this severe hemolytic anemia that can cause early death. In early 1980, its incidence in Cuba was calculated at 1 in 1600 births. In 1982, the Cuban public health system established the Sickle Cell Anemia Prevention Program, which aims to prevent the disease through identification of carrier couples and antenatal diagnosis of fetuses with disease-associated genotypes. In 1982-2018, hemoglobin genotypes were tested in 4,847,239 pregnant women. Of these, 168,865 (3.5%) were found to be carriers or to have sickle cell disease. During the same period, 8180 at-risk couples were identified, of whom 79.2% agreed to an antenatal study for detection of the sickle cell gene in the fetus. Among fetuses diagnosed, 20.1% had the SS genotype, the most clinically severe; 76.2% of the associated couples decided to interrupt the pregnancy. This program has resulted in a 3-fold reduction in prevalence of sickle cell disease in Cuba, a 10-fold reduction in the number of infants born with it each year, and a 16-year average increase in life expectancy of sickle cell disease patients of both sexes. Key contributors to these results have been universal screening of pregnant women in primary care, installation of diagnostic laboratories in every province, genetic counseling for couples, testing of fetal DNA (allowing couples to decide whether to continue the pregnancy if the fetus tests positive for the disease) and guaranteed multidisciplinary clinical care for patients. The Cuban experience shows that a middle-income country can mitigate the impact of a genetic disease through a universal preventive program based in primary care, which also pays particular attention to afflicted patients. KEYWORDS Sickle cell anemia, sickle cell disease, sickle cell disorders, hemolytic anemia, sickle cell trait, sickle cell hemoglobin C disease, HbS disease, prevention, antenatal screening, preventive health services, Cuba.

Cuban Meningococcal Vaccine VA-MENGOC-BC:30 Years of Use and Future Potential

Every year, meningococcal infection by Neisseria meningitidis causes over 500,000 cases and 85,000 deaths in the world, with 20% of survivors suffering sequelae. In Cuba its incidence in 1980 reached 5.9 cases per 100,000 population; about 80% of cases were serogroup B, prompting health authorities to declare meningococcal disease the country's main public health problem. Several provinces reported over 120 cases per 100,000 children aged < 1 year, overwhelmingly serogroup B. At that time, no vaccines existed with proven efficacy against N. meningitidis serogroup B, nor was there a vaccine candidate that could be successful in the short term. By 1989, researchers in Havana had developed a Cuban meningococcal B and C vaccine, VA-MENGOC-BC, the world's first against serogroup B meningococcal disease. Its efficacy of 83% was demonstrated in a prospective, randomized, double-blind, placebo-controlled field study. Vaccine production used vesicle or proteoliposome technology for the first time. The same year, the World Intellectual Property Organization awarded its gold medal to the main authors of the VA-MENGOC-BC patent. The vaccine was used in a mass vaccination campaign and later included in Cuba's National Immunization Program, with a cumulative impact on incidence of serogroup B meningococcal disease greater than 95% (93%-98%). Mass, systematic vaccination shifted the spectrum of meningococcal strains in healthy asymptomatic carriers and strains circulating among population groups toward nonvirulent phenotypes. The disease ceased to be a public health problem in the country. VA-MENGOC-BC is the most widely applied vaccine against serogroup B meningococcal disease in the world. Over 60 million doses have been administered in Latin America. In several countries where it has been applied, in which strains other than the vaccine-targeted strains circulate, VA-MENGOC-BC has demonstrated effectiveness against all (55%-98% in children aged < = 4 years and 73%-100% in children aged > 4 years). The vaccine and its proteoliposome technology have had an impact and continue to have potential, not only for meningococcal disease, but also for development of other vaccines and adjuvants.KEYWORDS Neisseria meningitidis, meningococcal disease, meningo-coccal vaccine, biotechnology, pharmaceutical industry, bacterial menin-gitis, meningococcal meningitis, immunization, vaccination, Cuba.

Cuba's Maternity Homes, 1962-2017: History, Evolution, Challenges

Cuba's maternity homes were founded in 1962 as part of the gen-eral movement to extend health services to the whole population in the context of the post-1959 social transformations. The over-arching goal of the homes was to improve the health of pregnant women, mothers and newborns. Hence, in the beginning when there were few hospitals in Cuba's rural areas, their initial pur-pose was to increase institutional births by providing pregnant women a homelike environment closer to hospitals. There, they lived during the final weeks before delivery, where they received medical care, room and board free of charge. Over time, and with expanded access to community and hospital health facilities across Cuba, the numbers, activities, modalities and criteria for admission also changed. In particular, in addition to geographi-cal considerations, expectant mothers with defined risk factors were prioritized. For example, during the 1990s economic crisis, the maternity homes' role in healthy nutrition became paramount. The purpose of this essay is to provide a historical perspective of this process, describe the changes and results during the 55 years examined, and take a critical look at the challenges to suc-cessful implementation of this model, a mainstay at the primary healthcare level of the public health system's Maternal-Child Health Program. KEYWORDS Maternal health, maternal-child health, obstetrics, pregnancy, Cuba.

Hereditary Ataxias in Cuba: Results and Impact of a Comprehensive, Multidisciplinary Project

Spinocerebellar ataxia type 2 is a degenerative disease that causes physical disability and, ultimately, prostration and death. Globally, reported prevalence is around 3 cases per 100,000 population and Cuba has the world's highest rates of the disease, affecting both patients and their at-risk descendants. In Holguín Province, which has the country's highest concentration of cases, incidence is 4.4 per 100,000 population and prevalence is 40.2 per 100,000 population. In 2000, a specialized research center was established in that province. Supplied with the necessary equipment and human resources, the center conducted national multidisciplinary studies involving molecular biology, clinical care, epidemiology, psychology, clinical neurophysiology, imaging, clinical genetics and community medicine, among others. A training and continuing education program also raised scientific capacity. Priority was given to developing international collaborations for academic exchange and training of Cuban researchers.Multiple results from research involving clinical and epidemiologic characterization of the disease, identification of biomarkers and therapeutic targets, genetic association studies, clinical trials and characterization of the disease's preclinical stages have been introduced in care of patients and their at-risk descendants. This has been accomplished through various programs including personalized rehabilitation, predictive diagnosis and social services. These results have also been published in high-impact scientific journals and received national and international awards. Such an experience in the context of Cuba's national health system-which is universal, free, accessible, comprehensive, prevention-oriented and with a record of international cooperation-demonstrates the possibility of providing quality care to affected families. Incorporating research findings into medical practice, with the resulting impact on patients' health and wellbeing, is a practical example of translational medicine in Cuba. KEYWORDS Spinocerebellar ataxia type 2, health services research, biomedical research. health care delivery, translational medicine, translational research, health equity, Cuba.

CUBA'S COVID-19 STRATEGY: UPDATED EPIDEMIC CONTROL AND RECOVERY MEASURES

MEDICC Review continues documentation of Cuba's COVID-19 Prevention and Control Plan and its implementation, begun with our April issue (see https://mediccreview.org/cubas-covid-19-strategy-main-actions-through-april-23-2020). This time, we present two tables: the first refers to measures taken to confront the epidemic, and the second, to the phased recovery process that is expected to lead to changes in many, if not all, sectors of Cuban society. In both cases, we have indicated the source of the information provided.

COVID-19 Forecasts for Cuba Using Logistic Regression and Gompertz Curves

INTRODUCTION On March 11, 2020, WHO declared COVID-19 a pandemic and called on governments to impose drastic measures to fi ght it. It is vitally important for government health authorities and leaders to have reliable estimates of infected cases and deaths in order to apply the necessary measures with the resources at their disposal. OBJECTIVE Test the validity of the logistic regression and Gompertz curve to forecast peaks of confi rmed cases and deaths in Cuba, as well as total number of cases. METHODS An inferential, predictive study was conducted using lo-gistic and Gompertz growth curves, adjusted with the least squares method and informatics tools for analysis and prediction of growth in COVID-19 cases and deaths. Italy and Spain-countries that have passed the initial peak of infection rates-were studied, and it was inferred from the results of these countries that their models were ap-plicable to Cuba. This hypothesis was tested by applying goodness-of-fi t and signifi cance tests on its parameters.RESULTS Both models showed good fi t, low mean square errors, and all parameters were highly signifi cant. CONCLUSIONS The validity of models was confi rmed based on logis-tic regression and the Gompertz curve to forecast the dates of peak infections and deaths, as well as total number of cases in Cuba. KEYWORDS COVID-19, SARS-CoV-2, logistic models, pandemic, mortality, Cuba.

Molecular evolution of coxsackievirus A24v in Cuba over 23-years, 1986-2009

Coxsackievirus A24 variant (CVA24v) is a major causative agent of acute hemorrhagic conjunctivitis outbreaks worldwide, yet the evolutionary and transmission dynamics of the virus remain unclear. To address this, we analyzed and compared the 3C and partial VP1 gene regions of CVA24v isolates obtained from five outbreaks in Cuba between 1986 and 2009 and strains isolated worldwide. Here we show that Cuban strains were homologous to those isolated in Africa, the Americas and Asia during the same time period. Two genotypes of CVA24v (GIII and GIV) were repeatedly introduced into Cuba and they arose about two years before the epidemic was detected. The two genotypes co-evolved with a population size that is stable over time. However, nucleotide substitution rates peaked during pandemics with 4.39 × 10-3 and 5.80 × 10-3 substitutions per site per year for the 3C and VP1 region, respectively. The phylogeographic analysis identified 25 and 19 viral transmission routes based on 3C and VP1 regions, respectively. Pandemic viruses usually originated in Asia, and both China and Brazil were the major hub for the global dispersal of the virus. Together, these data provide novel insight into the epidemiological dynamics of this virus and possibly other pandemic viruses.

Cuba's Pedro Kourí Tropical Medicine Institute:Battling COVID-19 One Study, One Test, One Patient at a Time

This MEDICC Review roundtable brings you specialists from Havana's Pedro Kourí Tropical Medicine Institute (IPK), who are working directly with testing, research and patient care during the COVID-19 pandemic. Founded in 1937 by its namesake, the Institute has gained considerable worldwide prestige. Today, it is a PAHO-WHO Collaborating Center for the Study of Dengue and Its Vector, and for the Elimination of Tuberculosis. Its main role within Cuba's health system is as the national reference center for prevention, control, management and elimination of infectious diseases, including epidemics. Its 479 workers staff 32 departments, including laboratories, research and teach-ing facilities, a hospital and isolation center. The IPK's hospital treats later-stage AIDS patients, while the Institute is the nation-al reference center for attention to all HIV-positive patients and maintains the national HIV/AIDS registry, as well as registries for other infectious diseases. The institution was responsible for training the Cuban doctors who served in West Africa during the 2014-2016 Ebola outbreaks and for those going abroad to assist in the COVID-19 response today, and its professionals offer an internationally-recognized biennial course on dengue.