INTRODUCTION Leprosy, an infectious disease caused by Mycobacterium leprae, affects the nervous system, skin, internal organs, extremities and mucous membranes. Biological, social and environmental factors influence its occurrence and transmission. The first effective treatments appeared in 1930 with the development of dapsone, a sulfone. The main components of a control and elimination strategy are early case detection and timely administration of multidrug therapy.

OBJECTIVES Review the history of leprosy control in Cuba, emphasizing particularly results of the National Leprosy Control Program, its modifications and influence on leprosy control.

EVIDENCE ACQUISITION The historiological method was applied using document review, complemented by interviews with experts on leprosy and its control. Archived documents, medical records, disease prevalence censuses conducted since 1942, and incidence and prevalence statistics for 1960–2015 from the Ministry of Public Health’s National Statistics Division were reviewed. Reports and scientific literature published on the Program and the history of leprosy in Cuba were also reviewed.

DEVELOPMENT Leprosy has been documented in Cuba since 1613. In 1938, the Leprosy Foundation was created with ten dispensaries nationwide for diagnosis and treatment. The first National Leprosy Control Program was established in 1962, implemented in 1963 and revised five times. In 1972, leper colonies were closed and treatment became ambulatory. In 1977, rifampicin was introduced. In 1988, the Program instituted controlled, decentralized, community-based multidrug treatment and established the criteria for considering a patient cured. In 2003, it included actions aimed at early diagnosis and prophylactic treatment of contacts. Since 2008, it prioritizes actions directed toward the population at risk, maintaining five-year followup with dermatological and neurological examination. Primary health care carries out diagnostic and treatment activities. The lowest leprosy incidence of 1.6 per 100,000 population was achieved in 2006. Since 2002, prevalence has remained steady at 0.2 per 10,000 population. Leprosy ceased to be considered a public health problem in Cuba as of 1993. In 1990–2015, 1.6% of new leprosy patients were aged <15 years. At present, late diagnosis of cases exceeds 20%, which leads to a high percentage of grade 2 disability in such patients. Spontaneous physician visits by already symptomatic patients surpassed 70% of cases diagnosed in 2010–2015.

CONCLUSIONS Actions undertaken after initial detection of leprosy in Cuba failed to control it. Effective control began in 1963, with the implementation of the National Leprosy Control Program, whose systematic actions have had an impact on trends in leprosy, reflected in WHO’s 1993 declaration that leprosy was no longer a public health problem in Cuba.

KEYWORDS Leprosy, Mycobacterium leprae, history of medicine, epidemiology, communicable disease control, Cuba

INTRODUCCIÓN Para alcanzar la meta de eliminar la tuberculosis como problema de salud pública en Cuba, deben comprenderse bien la evolución epidemiológica de la enfermedad y las estrategias diseñadas para prevenirla y manejarla hasta la fecha. En este contexto se introdujeron cambios en el Programa Nacional de Control de la Tuberculosis de Cuba en 1970.

OBJETIVO Revisar los antecedentes y la evolución de la estrategia de Cuba para controlar la tuberculosis, los cambios implementados en la revisión del Programa en 1970 y su impacto en la evolución posterior de la enfermedad en Cuba.

MÉTODOS Se revisaron los artículos publicados sobre la historia del control de la tuberculosis en Cuba, conjuntamente con documentos de archivo y registros médicos. Para el estudio se seleccionaron documentos relativos a la situación de la tuberculosis pulmonar en Cuba, que incluían la adopción de medidas para hacer frente a la enfermedad y su extensión, con énfasis en el período del Programa. Se realizaron entrevistas a informantes claves.

RESULTADOS La lucha de Cuba contra la tuberculosis comenzó en Santiago de Cuba con la creación de una Liga Anti-Tuberculosa local en 1890. Los cambios estratégicos introducidos en el sector de la salud pública en Cuba, que enfatizaban la promoción de salud y la prevención de enfermedades, llevaron a la creación en 1959 del Departamento de Tuberculosis, que implementó el primer Programa Nacional de Control de la Tuberculosis en Cuba en 1963. Este programa se reorganizó completamente en 1970. El Programa Nacional de Control de Tuberculosis (1963) incluía una red de 27 dispensarios de tuberculosis, 8 sanatorios y 24 laboratorios de bacteriología. El diagnóstico se basaba en criterios de las imágenes radiográficas. La incidencia era de 52.6/100.000 en 1964 y alcanzó 31.2 en 1970. El Programa se actualizó en 1970 para incluir dos cambios importantes: el requisito de confirmación bacteriológica del diagnóstico y el tratamiento ambulatorio supervisado directamente,  totalmente integrado dentro de los servicios de salud. Para 1971, la incidencia se había reducido a 17.8/100 000 y en 1979, llegó a 11.6. La disminución se interpreta como resultado de la mayor especificidad del diagnóstico microbiológico. El control de la tuberculosis ha seguido avanzando, y alcanzó una tasa de incidencia de 6.1/100 000 en 2012 y una tasa de mortalidad de 0.3/100 000 en 2013.

CONCLUSIONES Las modificaciones introducidas en el Programa Nacional de Control de la Tuberculosis en 1970 permitieron los resultados exitosos de las siguientes décadas: la reducción de la incidencia y la mortalidad por tuberculosis. Estos resultados también permitieron a las  autoridades sanitarias proponer la eliminación de la enfermedad en Cuba como un objetivo real.

PALABRAS CLAVE Historia de la medicina, tuberculosis, epidemiología, control de enfermedades transmisibles, salud pública, Cuba

INTRODUCTION To reach the goal of eliminating tuberculosis as a public health problem in Cuba, the epidemiological evolution of the disease and of strategies designed to prevent and manage it to date must be well understood. In this context, in 1970, changes were introduced in Cuba’s National Tuberculosis Control Program.

OBJECTIVE Review background and evolution of Cuba’s strategy for tuberculosis control, the changes implemented in the 1970 revision of the Program, and their impact on the subsequent evolution of the disease in Cuba.

METHODS Published articles on the history of tuberculosis control in Cuba were reviewed, along with archival documents and medical records. Documents concerning the situation of pulmonary tuberculosis in Cuba, including measures adopted to address the disease and its extent, were selected for study, with an emphasis on the period of the Program. Interviews with key informants were conducted.

RESULTS Cuba’s fight against tuberculosis began in Santiago de Cuba, with the creation of a local Anti-Tuberculosis League in 1890. Strategic changes introduced by Cuba’s public health sector, stressing health promotion and disease prevention, led to the 1959 creation of the Tuberculosis Department, which implemented Cuba’s first National Tuberculosis Control Program in 1963. This Program was completely reorganized in 1970. The National Tuberculosis Control Program (1963) covered a network of 27 tuberculosis dispensaries, 8 sanatoriums and 24 bacteriology laboratories. Diagnosis was based on radiographic imaging criteria. Incidence was 52.6/100,000 in 1964 and reached 31.2 in 1970. The Program was updated in 1970 to include two major changes: the requirement for bacteriological confirmation of diagnosis and directly-observed outpatient treatment fully integrated into health services. By 1971, incidence was down to 17.8/100,000, and further reduced to 11.6 in 1979. The decrease is interpreted as the result of the greater specificity of microbiologic diagnosis. Tuberculosis control continued to make progress, reaching an incidence rate of 6.1/100,000 in 2012 and mortality rate of 0.3/100,000 in 2013.

CONCLUSIONS Changes introduced in the National Tuberculosis Control Program in 1970 led to the successful results achieved in later decades, reducing tuberculosis incidence and mortality. These results also allowed health authorities to propose elimination of the disease in Cuba as a current objective.

KEYWORDS History of medicine, tuberculosis, epidemiology, communicable disease control, public health, Cuba

INTRODUCCIÓN La poliomielitis se detectó por primera vez en Cuba a finales del siglo XIX entre los residentes de una comunidad de estadounidenses en la Isla de Pinos (actualmente Isla de la Juventud), aparentemente introducida por la migración desde Estados Unidos. El primer brote se reportó en 1906 en esa localidad, y la primera epidemia ocurrió en la antigua provincia de Las Villas en 1909. Posteriormente, las epidemias se intensificaron y a partir de 1934 se presentaron periódicamente cada cuatro o cinco años, acompañadas por alta morbilidad, mortalidad y secuelas de invalidez, principalmente entre los niños.

OBJETIVO Revisar y analizar la historia de la poliomielitis y su control en Cuba desde la primera presentación de la enfermedad en 1898, hasta que la OMS-OPS certificó su eliminación en 1994.

MÉTODOS Se utilizó el método histórico; se revisaron documentos de archivo, historias clínicas e información estadística disponible de morbilidad y mortalidad por poliomielitis antes de 1959 y entre 1959 y 2000, provenientes de la Dirección Nacional de Estadística del Ministerio de Salud Pública. Se calcularon las tasas brutas de morbilidad y mortalidad a partir de los estimados poblacionales a mitad de período. Los informes y las publicaciones científicas que describen las campañas de vacunación y sus resultados también se revisaron y se entrevistaron especialistas y funcionarios que tuvieron una función protagónica en la organización y la ejecución de la campaña.

RESULTADOS En Cuba se registraron cinco grandes epidemias entre 1932 y 1958: en 1934 (434 casos y 82 fallecidos), 1942 (494 casos y 58 fallecidos), 1946 (239 casos y 33 fallecidos), 1952 (492 casos y 15 fallecidos) y 1955 (267 casos y 8 fallecidos). Entre 1957 y 1961 se presentó la enfermedad con carácter endemo-epidémico, y el último brote ocurrió en 1961 con 342 casos, de ellos el 30% eran niños mayores de cuatro años.

En 1962 Cuba realizó su primera campaña nacional de vacunación masiva. Esta fue la primera de las campañas anuales en el marco de un programa nacional coherente dirigido a la eliminación de la poliomielitis. Se aplicaron simultáneamente cinco millones de dosis de la vacuna oral Sabin en la primera campaña, que abarcó el 87.5% de la población infantil desde 1 mes hasta 14 años de edad, lo que constituyó el 109.4% de la cobertura planificada. A partir de ese año no se registraron muertes por poliomielitis (hubo diez casos no letales entre 1963 y 1989) y en 1994 la OMS-OPS certificó la eliminación de la poliomielitis en Cuba.

CONCLUSIONES Cuba ha controlado la poliomielitis con estrategias de vacunación efectivas y medidas epidemiológicas adecuadas en el contexto de un amplio apoyo social, financiero y político.

PALABRAS CLAVE Historia, poliomielitis, epidemiología, control de enfermedades, vacunación, vacuna Sabin, Cuba

INTRODUCTION Polio was first detected in Cuba in the late 19th century among residents of the US community on the Isla de Pinos (Isle of Pines, now Isle of Youth), apparently introduced through migration from the USA. The first outbreak was reported in 1906 on the Isle, with the first epidemic reported in the former province of Las Villas in 1909. The epidemics subsequently intensified, by 1934 becoming periodic every four to five years, and accompanied by high morbidity, mortality and crippling sequelae, primarily among children.

OBJECTIVE To review and analyze the history of polio and its control in Cuba, from the disease’s first appearance in 1898 until WHO/PAHO certification of elimination in 1994.

METHODS The historiological method was used; archival documents, medical records, and available polio morbidity and mortality statistics from the Ministry of Public Health’s National Statistics Division before 1959 and from 1959 through 2000 were reviewed. Crude morbidity and mortality rates were calculated using population estimates at mid-period. Reports and scientific publications describing polio vaccination campaigns and their results were also reviewed, and key informants were interviewed.

RESULTS After initial introduction of polio in Cuba, five major epidemics occurred between 1932 and 1958: in 1934 (434 cases, 82 deaths); 1942 (494 cases, 58 deaths); 1946 (239 cases, 33 deaths), 1952 (492 cases, 15 deaths) and 1955 (267 cases, 8 deaths). Between 1957 and 1961 the disease’s endemicity reached epidemic levels, with the last outbreak occurring in 1961, with 342 cases, 30% of them in children aged >4 years.

In 1962, Cuba launched a nationwide polio vaccination campaign, the first of annual campaigns thereafter carried out in the framework of a coherent national program aimed at polio elimination. Using the Sabin oral vaccine and targeting the entire pediatric population in a single time period, five million doses were administered in the first campaign, reaching 87.5% of the target population aged 1 month through 14 years, constituting 109.4% of planned coverage. Since that year, no deaths from polio have been recorded (there were ten cases between 1963 and 1989) and WHO/PAHO certified polio elimination in Cuba in 1994.

CONCLUSIONS Cuba controlled polio with effective vaccination strategies and appropriate epidemiological measures, in the context of social, financial and political support.

KEYWORDS History, poliomyelitis, epidemiology, disease control, vaccination, Sabin vaccine, Cuba