Cuba, one of the most-vaccinated countries

Philip Schellekens  |  
Cuba stands apart from most other countries when it comes to vaccine coverage and pandemic outcomes

Cuba produces its own vaccines, exports them and has one of the highest vaccine coverage ratios in the world. When it comes to pandemic outcomes, this seems to be paying off. Taking into account primary and booster vaccinations, Cuba is currently the most-vaccinated developing country in the world.


The Cuban vaccine landscape

Cuba stands apart from most countries for being a home-grown vaccine manufacturer. Also remarkable is the fact that Cuba’s vaccine landscape consists of 1- and, mainly, 3-dose protocols. This is exactly the opposite of the rest of the world, which relies disproportionately on 2-dose protocols. 

The country currently administers Abdala, Soberana 2 and Soberana Plus. Abdala is a 3-dose protocol, Soberana 2 combined with Soberana Plus is a 3-dose protocol for children, and Soberana Plus stand-alone is a 1-dose protocol for those with prior COVID. 

This diversity matters a great deal as it complicates the comparison of Cuba with the rest of the world (see also the note on Cuban vaccine landscape at the end of this post). Suppose country A administers only 3-dose vaccines and country B only 2-dose vaccines. If both A and B had vaccinated their entire population with a full primary cycle, then the vaccine coverage ratio (doses administered per 100 people) would be 300 in country A and 200 in country B. Yet, both countries would be equally well vaccinated. 

In other words, a plain comparison between Cuba and the rest of the world won’t be accurate since it would inflate Cuba’s vaccine coverage ratio. To address this concern, here’s a new method to compare global vaccination progress and avoid apples-and-oranges comparisons: we convert all doses administered into double-dose equivalents and we apply this transformation to every country in the world. In other words, we use the standard 2-dose protocol (which is the most common around the world) as a benchmark. 

In practical terms, we convert doses from 1-dose and 3-dose protocols into 2-dose equivalents by multiplying them by 2 and 2/3, respectively, before adding them up and dividing them by total population. t’s as simple as that.

Vaccination progress

In what follows, we will examine Cuba’s vaccination progress for the primary series and for boosters. We will then construct a total vaccination aggregate and compare Cuba with the group of developing countries and the world as a whole.

Primary vaccination

Using the above methodology, let’s examine the evolution of Cuba’s vaccine coverage ratio. Again, this ratio measures adjusted doses relative to the total population and achieves thanks to the adjustment a maximum of 200 when the population is fully covered or fully vaccinated as per the relevant vaccine protocols.  

We can immediately see that Cuba has done a stellar job. Initially, the vaccination effort had a slow start, although that was no different from any other country in the world. But around early summer 2021 Cuba accelerated its vaccination campaign and managed to raise coverage very rapidly. As a result, it caught up with China, which is also a front-runner at the global level. By now, Cuba has almost completed the primary vaccination cycle and is well ahead. Primary vaccine coverage is far higher than in most other countries, including other vaccine manufacturing nations. 

Booster vaccination

The chart below is a snapshot of global vaccination progress that dissects total vaccination into primary and booster vaccination. It shows all countries of the world (see the outer rim) and groups them according to the World Bank’s income classification into high income (HIC), upper-middle income (UMIC), lower-middle income (LMIC) and low income (LIC) countries. 

The vertical axis in this chart with polar coordinates represents two variables on different scales. The first in dark blue is the primary vaccine coverage ratio (as in the earlier chart), scaled from 0 to 200. The second in light blue is the booster coverage ratio (boosters, unadjusted, per 100 people) on a scale of 0 to 100 (100 for now, given that most countries are still pursuing their first booster cycle, while many have yet to start boosting). The 3-letter country codes in the outer circle are a little small, so CUB is highlighted in red. Look for it in the bottom-right quadrant of the UMICs. 

Global rankings for total vaccination

What would the international comparison look like if we were to consider “total vaccine coverage”? Total vaccine coverage takes into account primary vaccine and booster coverage simultaneously. That’s what the next visual is all about.  

Using the same methodology, we lump adjusted primary shots and booster shots into one composite indicator and express this relative to the total population. Let’s first look at the universe of developing countries and identify the top 20 countries among them in terms of total vaccine coverage. 

So here’s one interesting result: when it comes to total vaccine coverage, Cuba is currently the #2 in the developing world. That’s a remarkable achievement. It is the result of a solid performance in terms of primary vaccine coverage (where Cuba ranks #2) and booster coverage (where the country ranks #5).

The next chart shows the global Top 20 for total vaccine coverage. It tells us that Cuba’s performance not only stands out among developing countries but also in the world as a whole. Cuba currently ranks #5 worldwide, which is the result of being #4 on primary vaccine coverage and #17 on booster coverage.

Pandemic outcomes

Cuba’s high vaccine coverage ratio seems to be paying off when we look at the country’s pandemic outcomes. In what follows, we’ll discuss cases and fatalities and make some international comparisons. 

Let’s start with the domestic picture first. The chart below traces the evolution of confirmed cases and deaths both expressed per million people. These are daily numbers calculated as a weekly trailing average.

What is most striking in the above chart is the muted nature of the recent Omicron/Delta surge. New cases in Cuba did not exceed – and neither did they even approach – their previous peak, which stands in sharp contrast to most other countries in the world. In the same vein, the impact on mortality has been small, which is a more common pattern internationally. 

Let’s discuss this in some more detail and compare Cuba’s experience with that of other countries, focusing on cases first. The charts below show peak case rates before and after the Omicron/Delta surge, where the cutoff date is taken to be November 1, 2021. So for the peak case rate prior to this date we calculate the maximum daily peak (again on a weekly trailing average basis) observed over the entire period of the pandemic up till the cutoff date. For the period after November 1, we do the same and calculate the peak value which will capture the most intense moment of the recent Omicron/Delta wave. 

Cuba reached its all-time peak in cases before the recent Omicron/Delta wave (around August 2021). Vaccination around that time had only just started to accelerate. But as the second chart shows the peak case rate during the Omicron/Delta wave has been very low in comparison to other countries.

We know that vaccines are less effective in protecting against infection than in preventing severe outcomes of morbidity or mortality. The chart below examines the mortality peaks before and after November 1, 2021 and compares them across countries. Prior to the most recent wave, the mortality rate was on the lower end compared to other UMICs. But what is most striking is the performance during the most recent wave, where Cuba managed to keep mortality at very low levels compared to other UMICs and indeed the rest of the world.  

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Cuba’s experience has been truly remarkable. The country stood out in terms of developing and producing its own vaccines. Thanks to that, it was able to ramp up vaccine coverage very quickly – a home bias advantage that other vaccine manufacturing nations have enjoyed.  Success on the vaccination side seems to have resulted in some very good pandemic outcomes, especially on the mortality side. Other factors are of course at play, but the results are nevertheless impressive.

Cuba’s story is a story that we would like to see repeated elsewhere around the world. It is fundamentally important for vaccine production to be less geographically concentrated and for manufacturing capabilities to be more widely shared. 

Looking ahead, we don’t know what Mother Nature has in store for us. It may well be the case that another dangerous variant pops up that will challenge existing immunities and vaccines. It is for that fundamental reason that the Cuban experience needs to be emulated.

Annex: Cuban vaccine landscape

As mentioned in the main text, Cuba’s vaccines are mostly 1- and 3-dose protocol vaccines, where most of the doses administered belong to the 3-dose variety. The vaccines are: Abdala (3-dose vaccine), Soberana 2 combined with Soberana Plus (considered a 3-dose vaccine for children) and Soberana Plus stand-alone (considered a 1-dose vaccine for those with prior COVID). Note that, in the data that Cuba publishes, Soberana Plus when combined with Soberana 2 is treated as the third dose of a three-dose vaccination protocol and not as a booster.

How do we take into account this diversity of vaccines in the adjusted vaccine coverage indicator where doses are converted into double-dose equivalents? The logic is simple but getting the numbers adjusted requires a few permutations. 

  • We first need to scrape the data making sure we include among our variables the numbers for (1) total doses administered, (2) people vaccinated with three doses and (3) people fully vaccinated (data which is presently not available at Our World in Data). 
  • We then calculate total doses administered under the 1-dose protocol (Soberana Plus stand-alone) as (3) – (2). Total doses administered under 3-dose protocols (Abdala and the Soberana 2 and Plus mix) equal (1) – (3) + (2) . 
  • The final step is to multiply the single-dose protocol doses by 2 and the three-dose protocol doses by 2/3. Add up everything and then we have our adjusted measure that is comparable across countries. 

The Cuban case illustrates the value of the adjusted indicator. To see this, let’s pick the arbitrary date of October 29, 2021 and compare the unadjusted and adjusted indicators. If we were to use plain doses per capita, Cuba’s vaccine coverage rate on this date would be 225 doses per 100 people. The adjusted coverage ratio on the other hand would be 154 doses per 100 people. This is a lot lower than the unadjusted number because currently about the vast majority of doses administered in Cuba belong to 3-shot protocols. 

Without the adjustment, we would be comparing apples and oranges. With it, we can make a correct comparison of vaccination progress across countries irrespective of the particular vaccine mix they have been using.

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