Mission

To maintain and strengthen the practice of Epidemiology and Surveillance for improved policy formulation, implementation and evaluation of programmes for the prevention and control of public health problems.

Introduction

During 1999, the Epidemiology Division continued to work collaboratively with the member countries to build their national capacities in epidemiology and public health surveillance and to secure re-affirmation of the countries’ commitment for such. In this regard, new surveillance systems were established; existing systems were evaluated with a view to strengthening; country staffs were trained in a variety of related areas and outbreaks were investigated. Our programmatic areas of focus included General Communicable Disease Surveillance; Tuberculosis, Leprosy and Nosocomial Infection Control; Injury Surveillance and Health Statistics.

During the period under review, the staff of the Division included three CAREC professional epidemiologists, another epidemiologist, funded by the French Technical Cooperation, two systems analysts, two data entry technicians, two administrative co-ordinators, three secretaries and a Manager. The Division had been unable to recruit a biostatistician until November, and the services of the PAHO biostatistician had only been available up through May, 1999.

Our ability to effectively respond to the ever increasing and widely diverse needs of our member countries is being continually challenged, given our current infrastructural and financial resources. However, the Division has taken the strategic decision to adopt the Caribbean Cooperation in Health-II (CCH-II) as the framework within which the Division will function. While CAREC has the lead organisational responsibility for the priority area on the Prevention and Control of Communicable Diseases, there are certain critical inputs which must also be provided, in order to assure that some of the essential requisites for achieving the goals of CCH-II are met.

Areas of Major Achievement

Specific Technical Areas

General Communicable Diseases Surveillance

During 1999, the Division continued to provide technical assistance, advice and support to member country personnel in order to strengthen their national epidemiology and surveillance functions. While considerable progress and improvements have been made in these areas over the past twenty-five years, insufficient numbers and inadequately trained human resources continue to be major deterrents to achieving even more significant gains, commensurate with the region’s developmental needs at this time. We recognize that in many of our member countries, the responsibility for epidemiologic and surveillance functions often resides with a staff member who already bears other full responsibilities either as the Medical Officer of Health or the Director of Primary Health Care. As a consequence, these areas are routinely not accorded high priority, except possibly in the event of an outbreak emergency and, hence, systematic development of the practice of epidemiology and surveillance is not easily sustained. This is the canvas on which the Division must work.

There was continued emphasis on the important need for the collection, collation, analysis, interpretation and dissemination of quality and timely surveillance data. While all of our member countries must be congratulated for sustaining improved data quality, as evidenced by a reduction in the number of reports needing to be queried because of inconsistencies or inaccuracies, untimely reporting has become a cause for serious concern. During the latter half of 1999, over 40 percent of the weekly communicable disease reports were received more than eight weeks past their due date. This degree of tardiness does not facilitate timely action and response to emerging public health problems. During the new year, more emphasis will be placed on the critical need to translate this data into information for decision making and action. The Division notes with pleasure, however, that the surveillance data is being analysed and disseminated, as evidenced by the sustained production of regular epidemiologic bulletins and reports in some countries such as Jamaica, the British Virgin Islands, Antigua and Barbuda and Trinidad and Tobago. In others, for example, Guyana, periodic but comprehensive reviews have been produced (Health Review: Statistics and Analysis for Planning, July 1999).

Over the period, general as well as specific surveillance systems were reviewed in seven member countries. Systems in Trinidad and Tobago, Jamaica and St. Lucia were evaluated as part of the Physician-based Sentinel Surveillance Project (PBSS), while a Suriname review was focussed on vector-borne diseases and the integration of laboratory information into their general surveillance. General reviews were conducted in the British Virgin Islands, St. Vincent and the Grenadines and Anguilla. In October 1999, a multidisciplinary CAREC team paid a familiarization visit to the Netherlands Antilles in order to assess the structure and functions of their health and epidemiologic systems. It was noted that their structures and processes, both at the political and health levels, differed significantly from those in the former British colonies, and, hence, creative strategies and mechanisms will have to be developed, if the Division and the Centre are to work effectively with this five-island union.

In general, it has been noted that the health sector reform process has impacted on the efficient and effective conduct of surveillance, in some countries. For example, in Trinidad and Tobago, where there is a transition from older structures towards decentralized regional systems, there has been a weakening of the traditional surveillance structure as they await implementation of new structures. As a consequence, existing human resource difficulties have been further exacerbated, as adequate numbers of appropriately trained staff are required to man these regional surveillance systems. In response to these developing situations, the Division conducted a workshop for personnel from the Ministry of Health, Trinidad and Tobago entitled "HIV/AIDS Surveillance in a Decentralized Environment". This activity, which was funded by the CAREC-CIDA project, was targeted to a wider audience of public health staff from the five health regions, including hospital infection control personnel.

During 1999, significant technical time and resources were directed to building consensus among key stakeholders and in the final development and production of the document entitled "Public Health Surveillance: A Caribbean Communicable Disease Manual for Action." This document was born out of the unanimous request of the national epidemiologists and laboratory directors, who recognized the need for such a tool and urged CAREC to undertake its development in 1997. This manual has been developed, inter alia, to be a reference document to enhance member countries’ capacity to undertake communicable disease surveillance and outbreak investigations at various levels of the health system; to introduce new concepts and approaches for the conduct of disease surveillance; to provide regional standards for communicable disease surveillance and serve as a basis from which national standards could be established. This manual will be operationalized during the year 2000.

A meeting of the national epidemiologists and laboratory directors was convened in June 1999, the theme of which was "Visioning for Health within the Framework of CCH-II: 2000 and Beyond." Significant agenda items at this meeting included, inter alia, the implications of health sector reform and the Caribbean Cooperation in Health Phase II for the practice of epidemiology; communicable disease priorities and new surveillance approaches for the new millennium; and building and sustaining public health capacity in the region.

The Epidemiology team continued to analyse and interpret incoming country data, translating it into information which was communicated to our key stakeholders through the Communicable Disease Feedback Reports, Fax Alerts and postings on the CAREC Website. Our ability to generate enhanced disease profiles was facilitated through electronic access to laboratory data from CAREC’s Laboratory Information System (LABIS) system, from which trends in laboratory referrals as well as diagnoses could be monitored. Modifications to this system have been recommended, in order to further enhance its epidemiologic utility.

During the period under review, there was substantially increased utilization of a variety of international electronic databases by the Epidemiology Division. ProMED has proved to be an invaluable resource for information related to emerging and re-emerging infectious disease situations. The European Working Group on Legionella Infections (EWGLI) has provided CAREC with the only source of data on Legionella infections among European travellers returning from the Caribbean. Numerous other electronic databases (for example, those hosted by the US Centers for Disease Control and Prevention; the World Health Organization; the Pan American Health Organization; the United Kingdom Public Health Laboratory Service; Health and Welfare, Canada; the French BEH and FLUNET) have been regularly screened with a view to accessing global health information which may have implications for the Caribbean.

Pursuant to CAREC’s continued efforts to strengthen surveillance for HIV infections and Acquired Immunodeficiency Syndrome in its member countries, the Divisional Manager initiated, in 1999, discussions with staff of the Ministries of Health in Trinidad and Tobago and Anguilla, in order to assess the feasibility for conduct of HIV sero-prevalence studies among pregnant women in these territories. Both countries have developed proposals and project implementation has commenced in one territory.

Brief Morbidity Review

Of those diseases subject to the International Health Regulations, only cholera was reported in the sub-region during 1999, and exclusively so from Belize (Appendix 1: Annual Cumulative Totals of Reported Cases of Communicable Diseases, 1998–1999). A real decline was noted in the reported incidence of rubella and congenital rubella syndrome, further details of which have been highlighted in the section on vaccine preventable diseases. During 1999, reported morbidity due to gastroenteritis, both in the under and over five populations, exceeded that recorded for 1998. A greater than two-fold increase in the reported incidence rate for gonococcal infection was observed in 1999 as compared with the 1998 situation (Figure 1). Although only notified from seven CMCs, the chlamydia infection incidence rate for 1999 was also higher than that reported during 1998.

During 1999, both the absolute number of reported cases of syphilis as well as the incidence rate were higher than that recorded during the previous year. Greater influenza morbidity was also recorded in the sub-region during 1999. The traditional seasonal pattern of high viral circulation during the early months of the year has, however, been consistent (Figure 2).

Reported morbidity due to dengue fever in 1999 was significantly reduced as a sub-regional incidence rate of 62.4 cases per 100,000 population was recorded as compared with 104.0 cases for 1998. Significant dengue fever activity was, however, documented in Suriname, where a national incidence rate of 367.7 cases per 100,000 population was observed in 1999 (Figure 3).

New Initiatives

The Physician Based Sentinel Surveillance Project (PBSS)

The Physician Based Sentinel Surveillance Project (PBSS) for Emerging Diseases and Health problems, which is being funded by the Information for Development (InfoDev) Programme of the World Bank, progressed from a developmental mode into one of implementation during 1999. Conceived as a pilot project for establishing computer-based sentinel surveillance among private sector physicians, the project commenced operations during the first quarter of 1999 with the procurement and installation of computers and hardware for twenty-one (21) participants in Jamaica, St. Lucia and Trinidad and Tobago. The project represents a cooperative venture with the Caribbean College of Family Physicians (CCFP) and respective Ministries of Health in the target countries.

Figure 1 Reported Cases of Gonoccocal Infections by Week
Reporting Period: Weeks 1–52: 1998 and 1999. All CAREC Member countries

Figure 2 Reported Cases of Influenza by Week
Reporting Period: Weeks 1–52: 1998 and 1999. All CAREC Member Countries

Figure 3 Reported Cases of Dengue by Week.
Reporting Period: Weeks 1–52: 1998 and 1999. All CAREC Member Countries

A collaborative process was utilized for developing the surveillance instrument and an Epi Info-based reporting program for three disease syndromes, namely, fever/rash syndrome, diarrhoeal disease and sexually transmitted infections (STIs). A menu-driven program was employed to facilitate the on-site analysis of individual site data using a standard report format, as well as enabling secondary analysis of aggregate data at the Ministry of Health and regional levels. Concurrently with the development of the program software, introductory training sessions were conducted in the areas of surveillance, the reporting procedures governing this network and use of the software. Internet connections were also utilized for communication and information dissemination among project participants.

Between September to October 1999, data entry by the participants was commenced on a phased basis. During the last quarter of 1999, an evaluation of the data entry and reporting processes was undertaken and appropriate modifications were made to the software program. Initial steps towards the development of a Windows-based version and a compatible patient management program were also pursued during this quarter. Additionally, mechanisms to enable the epidemiology/surveillance units of the target Ministries of Health to receive, analyze and act on PBSS surveillance data were also explored.

As at December 31, 1999, forty-two (42) participant-months of data were received from thirteen of the twenty-one sentinel physicians. A brief analysis of the data by country and syndromes is presented in the following table (Table 1).

Table 1 Reported PBSS Data¹

¹Based on reports received as at December 31, 1999

This review is not intended to be an epidemiologic analysis of the PBSS data, but is being presented here only to demonstrate this project’s potential for expanding the surveillance database at the national and regional levels. No sound conclusions or meaningful comparisons should be drawn at this time owing to a number of data limitations, neither should the data be taken to be representative of any specific epidemiologic situations in the respective countries.

During the second year, the project will further its efforts to facilitate the alignment of this surveillance system more closely with the routine reporting of the national Ministries, and to strengthen and widen the feedback loop through an expanded online forum. Additionally, the use of PBSS sentinel physicians as part of an enhanced regional programme for influenza and dengue fever surveillance has been proposed, and will be actively explored during Year 2, in conjunction with the Laboratory Division, the PAHO Virologist and the respective Ministries of Health.

The Public Health Laboratory Information System (PHLIS)

PHLIS is a PC-based software application that was originally developed by the US Centers for Disease Control and Prevention (CDC) for salmonellosis surveillance. It facilitates a hierarchical reporting scheme through which data is transmitted from lower level reporting sites to higher level sites. During 1998, CAREC and several of its member countries received technical, financial and infra-structural support from the US-based Walter Reed Army Institute of Research (WRAIR) for the development of a public health laboratory information system in the Caribbean. The major aim of this initiative was the establishment of a communication network between in-country laboratories and epidemiologists at the country level, and between countries and CAREC at the regional level.

During 1999, an implementation proposal was finalized for the project. CAREC was organised as the top-level site in the network and a helpdesk was established here to assist participating countries with queries concerning data capture and transmission. Preliminary orientation meetings were convened in eleven (11) member countries, which included Barbados, St. Vincent and the Grenadines, Antigua and Barbuda, Montserrat, Dominica, St. Lucia, Jamaica, Aruba, the Turks and Caicos Islands, Suriname and Belize. The specific purpose of these meetings was to introduce the project concept and its objectives to potential key stakeholders, to ensure that all of the practical issues related to its implementation were understood, and to finalize arrangements for project-related training and implementation.

During 1999, training in the application and use of PHLIS was conducted and the system operationalised in three member countries, namely, Trinidad and Tobago, Antigua and Barbuda and Barbados. Extensive technical assistance and follow-up PHLIS training was provided to Trinidad and Tobago. A half-year progress report was produced and distributed to all CAREC member countries. Development of a dengue fever module was commenced. The PHLIS data received to-date from two CMCs, while weak from a surveillance perspective, have been extremely revealing from the standpoint of laboratory quality assurance. It is, therefore, evident that in addition to the surveillance utility of this database, it could well serve as an adjunct laboratory evaluative tool. It is planned that in the year 2000, preliminary meetings will be convened in at least six more member countries, while ten (10) additional countries will join the network.

Outbreak Investigations and Disaster Response

Hepatitis A Viral Outbreak — Belize

During the months of January and February 1999, an increase in the number of reported cases of jaundice was observed in the Cayo health district of Belize. Ten cases of jaundice had been reported among children, aged 4 through 12 years and one death was recorded on January 10, in an 11 year old boy who had been diagnosed with hepatitis B. This child had died at the Melchor hospital in Guatemala. During the same period, 2 cases of jaundice were notified among adults.

A joint team, consisting of the national epidemiologist and public health nurses from the Ministry of Health in Belize and a CAREC epidemiologist, conducted an epidemiologic investigation of five clusters of suspected cases of leptospirosis in the Cayo district. These cases were interviewed and through active surveillance a further 6 were identified, resulting in a total of 16 cases among children, aged 4 through 12 years. These patients exhibited very mild clinical symptoms, which were compatible with the case definition for hepatitis A. Five cases, from 3 of the 5 clusters, were confirmed as viral hepatitis A infections by IgM serology. The two jaundiced adults did not meet the case definition for hepatitis A. One was a confirmed case of sickle cell anaemia and the symptoms of the other were more closely compatible with the case definition for leptospirosis.

In summary, an outbreak of viral hepatitis A was confirmed among children, aged 4 to 12 years, from 5 different clusters in the Cayo district. While there was no statistical evidence to link any specific exposure to the occurrence of this outbreak, transmission of the aetiologic agent through frozen drinks was suspected.

Disease Control Programmes

Leprosy

Leprosy has been targeted for global elimination by the World Health Organization in the year 2000. The elimination target of one case per 10,000 population has been realized in all of the CAREC member countries, with the exception of Suriname and St. Lucia, where 1998 prevalence rates of 2.2 and 1.58 were recorded, respectively.

During 1999, intense efforts and resources, including inter-country collaboration for training, were directed towards promoting awareness of the disease in those countries, from which new cases continued to be notified. In this regard, particular attention was paid to Suriname and St. Lucia from which 62 and 8 incident cases were reported, respectively, during 1998. This heightened awareness resulted in three cases being self-referred in the latter country. Disability prevention and rehabilitation continue to be the major emphases of control at this time.

CAREC’s technical focal point has continued to work collaboratively with the Ministries of Health to facilitate a discussion on the integration and sustainability of national leprosy services as health sector reforms including decentralisation and rationalisation of services are introduced. Whatever the final configuration of the national services, early case detection and successful management must continue to be assured for this disease of low endemicity.

The Netherlands Leprosy Relief (NLR) continued to provide generous financial support for multi-drug therapy, training as well as health educational materials, to Jamaica and St. Lucia through CAREC, while Guyana, Trinidad and Tobago and Suriname continued to receive direct bilateral support.

An evaluation of the leprosy control programmes in Jamaica, St. Lucia, Guyana and Trinidad and Tobago was undertaken by a joint NLR/CAREC team during 1999, and the level of available services and activities for surveillance, diagnosis and monitoring were found to be very satisfactory.

Through technical cooperation efforts, the programme in Suriname was able to provide special shoes for seven patients in St. Lucia.

Tuberculosis

During 1999, the Division’s technical focal point continued to work assiduously to ensure that member countries adopted and utilized effective management and control strategies in order to increase clinical awareness and facilitate the early identification, treatment and cure of cases of tuberculosis. Managers were reminded of the importance of data analysis employing those indicators recommended by the WHO, and of using the results to adjust programme activities for enhanced efficiency and effectiveness. In this regard, the active use of standard registers and procedures has been repeatedly emphasised.

Tuberculosis programmes in Trinidad and Tobago, St. Lucia and Guyana were closely monitored during 1999. The findings of a retrospective cohort analysis, which was conducted in Trinidad and Tobago during 1998, were shared with the Ministry of Health at a workshop in 1999 and these findings were utilized to generate a draft national tuberculosis policy for that country. The findings of a similar study undertaken in St. Lucia will be shared with health authorities there in the new year.

It is with concern that we note that data on TB/HIV co-infection is not readily and consistently available in some countries as systematic testing of tuberculosis cases for the human immuno-deficiency virus infection is yet to be established. It has been well documented that persons with TB/HIV co-infection are less likely to comply with treatment regimens, thus increasing the potential for development of drug-resistant mycobacterial tuberculosis. In the Caribbean, as in other developing countries, individuals with HIV/AIDS often experience socio-economic difficulties, which may preclude them from accessing appropriate health care. It should therefore be emphasized that inappropriately treated or untreated cases of tuberculosis pose a serious threat to the public’s health as such persons will continue to transmit their pathogenic organisms.

In view of the status of existing tuberculosis control programmes and the potential for an increased number of TB/HIV co-infections, the Pan American Health Organization facilitated preceptorships for a number of persons from selected member countries. The major objective of these preceptorships, which were tenable at the Tuberculosis Model Programme in New Jersey, USA, was to improve clinical expertise in tuberculosis control. Three physicians and two co-ordinators from the Bahamas, Trinidad and Tobago and Guyana were able to participate through funding which was made available from the CARICOM/GTZ TB training programme (one participant from the Bahamas was funded through country funds). It is anticipated that these officers will act as change agents for an improved tuberculosis service. It is also hoped that the critical areas necessary for effective and efficient tuberculosis control will be established and that a practical approach for the care of dually infected persons will be adopted in their individual national programmes.

Nosocomial Infection Control

Although the Division does not currently have a specific funding stream to more fully support this area, we did provide direct technical support and co-ordination to Trinidad and Tobago for a workshop, which was hosted by the Trinidad and Tobago Association of Registered Nurses in August 1999. Nine participants were oriented to the principles of hospital infection control through didactic lectures and practicums.

The Division will pursue the development of a Caribbean manual on the control of hospital infections during the new year. We believe that such a document would be beneficial at this time as the clinical services provided by the government sector undergo changes as part of the health sector reform process and quality issues are emphasized. Additionally, the concomitant expansion in the number of hospitals and nursing homes in the private sector as well as the increasing incidence of antibiotic resistance necessitate more focussed attention to this area. Emphasis must be placed on the development of infection control programmes in which the physicians and hospital administrators must play essential roles.

Health Statistics

Health Needs Assessment

Consequent to earlier agreements, the Epidemiology Division initiated the ground work for the analysis of a health needs assessment survey, which was undertaken by the Ministry of Health in St. Christopher/Nevis. Four hundred and eleven (411) individual instruments were received representing a total of one hundred and eighty eight (188) households. These questionnaires have all been edited, coded, entered and validated using the EpiInfo software. Data analysis has commenced and will include bivariate and multivariate methods. A draft report is planned for the end of the first quarter 2000.

Technical statistical assistance and advice were provided for the analysis of the Tobago Youth Health Needs Assessment Survey. This specific survey represented the first phase of a youth sexual health promotion project which has been mounted in Tobago and its findings will be used to support behavioural change interventions targeted to young persons, aged 10 through 24 years.

Mortality Data

During 1999, the sub-regional mortality database was further updated with the receipt of data from St. Christopher/Nevis (1996–1997); Grenada (1996–1997); Dominica (1996–1998); the British Virgin Islands (1996–1998) and Anguilla (1998). The raw data received from the British Virgin Islands has been analysed and the relevant frequency tables generated. Further analyses are planned in order to derive additional health indicators, which could serve as the standard for the regional mortality data. It is also envisioned that this data would be posted on CAREC’s website to facilitate wider dissemination.

Injury Surveillance

Our attempts to pilot the IDRC-funded, Caribbean hospital-based injury surveillance system in the Bahamas, Trinidad and Tobago and Barbados have met with mixed success. Although the three countries had originally agreed to an integrated system within the Accident and Emergency Departments of their major hospitals, this was only successfully achieved in the Bahamas. Unfortunately, however, major issues related to the grounding and sustainability of the project in the Bahamas have arisen as the original technical focal point has now assumed different roles and responsibilities within the newly reformed health sector in that country.

Although Trinidad and Tobago had expressed specific interest in this surveillance system, an unforeseen delay was encountered as the decision was taken to await the advice of a consultant as regards the upgrading of the entire national health information system as part of the country’s health sector reform process. This was deemed to be necessary in order to facilitate the successful integration of the injury surveillance system. Jamaica, although not part of the original pilot, was able to establish and operationalize another system in five major hospitals, having recognized the strategic need for quantifying and prioritizing injury-related problems and for assessing and planning for rational allocation of resources. In December 1999, CAREC in collaboration with personnel from the US Centers for Disease Control and Prevention (CDC) conducted an evaluation of that computerized system at these hospitals and noted that there was need for some degree of modification in order to ensure accurate capture of required data elements and completeness of reporting in terms of the quality of relevant data.

Training Initiatives

Applications in Health Information Management (Level 2)

The Epidemiology Division continued to work collaboratively with the Human Resource Development Adviser from the PAHO Office of Caribbean Programme Coordination in the delivery of a workshop entitled "Applications in Health Information Management – Level 2". This specific initiative, which is part of a wider human resource development project being funded from the W.K. Kellogg Foundation, is intended for middle and upper level health professionals who are required to provide and use information for planning and decision making.

Staff of the Epidemiology Division conducted a series of in-country training workshops, which emphasised principles of epidemiology; data collection and analysis; and the use of the Epi Info software application. These exercises were convened in eight (8) CAREC member countries, which included Antigua and Barbuda; St. Vincent and the Grenadines; St. Lucia; Dominica; St. Christopher/Nevis; Grenada; Barbados and Montserrat. These workshop participants were introduced to the Internet as well as to a number of software applications, such as Microsoft Word, Excel and PowerPoint. Principles of project management, decision making and presentation techniques were also taught as part of this package. Participants delivered two group presentations, one at the end of the two-week workshop based on the analysis of either a real or contrived health problem. Some participants also elected to computerize a few of the data collection instruments that were in current use at their ministries. Following the workshop, participants worked on a project of their own choice over a six-week period and presented their findings at the end of this period.

Results of the course evaluation questionnaires, pre- and post-test exercises and group presentations suggested that the short term impact of the workshop was very positive. The workshops generally met the expectations of the participants, who reported that they had found it very relevant to their needs.

Other Training Initiatives

In January 1999, the medical epidemiologist being supported by the French Technical Co-operation Agency, traveled to El Salvador as part of a teaching faculty which conducted a training workshop for national epidemiologists and laboratory directors from Central America and the Dominican Republic. This PAHO sponsored workshop was mounted as follow-up a response to the disasters, which had resulted from Hurricanes Mitch and Georges. Principles of outbreak investigation and related laboratory support issues were emphasised, especially with regard to cholera, dengue fever, malaria and leptospirosis.

In November 1999, two Divisional epidemiologists conducted a three-day training workshop on the principles and practice of outbreak investigation and management for staff of the Ministry of Health in Belize. Thirty public health inspectors and nurses participated in this exercise. Additionally, six public health physicians were oriented to the role of the physician within a multidisciplinary team that is conducting an outbreak investigation.

Vaccine Preventable Diseases

During 1999, the Epidemiology Division continued to work closely with the Expanded Programme on Immunization in developing new surveillance systems and in refining existing systems for vaccine preventable diseases. An invasive bacterial surveillance system was specifically established in four CAREC member countries to monitor the prevalence of Haemophilus influenzae, Streptococcus pneumoniae and Neisseria meningitidis among children less than 11 years of age, presenting to health institutions with pneumonia, meningitis or septicaemia. The data emanating from this initiative will be used to assess the impact of HIb (Haemophilus influenzae, type b) immunisaton in those countries where it has already been introduced, and to assist other countries in deciding which would be the best age group to be targeted for immunisation. This system is being piloted in Trinidad and Tobago, Barbados, St. Vincent and the Grenadines and Jamaica.

The surveillance system for congenital rubella syndrome (CRS), which was first initiated in 1996 and later refined in 1998, has proved itself to be an extremely valuable tool for evaluating the changes in CRS morbidity. The decline in the number of reported cases of congenital rubella syndrome observed during 1999 has been due to a real reduction in rubella virus activity in the Caribbean. This epidemiologic situation would be due in part to a depletion of susceptibles following the epidemic years of 1997 and 1998, as well as an increase in artificially acquired immunity resulting from the adult mass vaccination programmes, which have achieved a roughly 50 percent coverage rate of the target population (Figure 4).

Figure 4 Reported Cases of Rubella and Congenital Rubella Syndrome
All CAREC Member Countries, 1996–1999

Human Resource Development

In order to continually update and enhance our knowledge and skills to meet the ever-changing challenges of the workplace, associates of the division attended or participated in a number of training courses or related activities during the year.

In July 1999, the PHLIS Project Coordinator attended the Graduate Epidemiology Summer Programme hosted by the University of Michigan, USA. Subject areas discussed as part of this update included topics in general infectious diseases; emerging and re-emerging infectious diseases; the epidemiology of violence; and biomarkers. Additionally, an opportunity was provided for the PHLIS coordinator to participate in a week-long conference entitled "Emerging Infections: Challenges for the 21st Century", which was hosted by the US Southern Atlantic Command in Florida USA during September, 1999.

The Division’s technical focal point for tuberculosis attended the IUALTD (The International Union Against Tuberculosis and Lung Diseases) North American Meeting in Chicago Illinois, in February 1999. This meeting specifically focussed attention on Tuberculosis-HIV co-infections. Two salient points arose for the Caribbean, based on the discussions from this meeting. These included the important need for surveillance of dually infected persons and the critical need for the implementation of the directly observed therapy-short course (DOTS) in that group, as dually infected persons tend to be less adherent to their treatment regimens.

The Division’s technical focal point for nosocomial infection control participated in a preceptorship at the St. Bonniface Hospital in Manitoba, Canada during August 1999. During this study tour, our associate had a practical orientation to a number of laboratory and clinical situations related to nosocomial infections.

Training was provided for one of the Division’s systems analysts in Administering and Supporting Microsoft SQL Server 7.0. The adoption of this application by CAREC’s laboratory will facilitate improved electronic connectivity between the Epidemiology Division and the Laboratory Information System (LABIS).

Secretarial support staff were updated in Modern Techniques for Minute Taking, while one member has been participating in a Programme on Translating and Conference Interpreting (Spanish/English).

Electronic Systems Support: Data Issues and Developments

Improving Data Quality

During 1999, a computerised information system (CDRSYS) was developed for use in member countries to facilitate the capture, retrieval and analysis of their weekly communicable disease data. The system was further fine-tuned and is currently being piloted in two member countries. Most of the weekly communicable disease reports from our member countries are currently forwarded to the Epidemiology Division as faxed communications. This computerised system will provide countries with the option of printing reports or generating a file of weekly reports, which could then be forwarded to CAREC via the e-mail, at which time it would be appended to our regional database, EPISUMM. Such a development would therefore eliminate the need for manual data entry. This system would also facilitate the capture of weekly data from individual reporting units within a country.

Acquired Immune Deficiency Syndrome (AIDS) Reporting

Most of our member countries are to be applauded for their continued efforts in producing their AIDS Quarterly surveillance reports on a timely basis. More than 80 percent of these reports were received in good time, with few numeric and classification errors. Pursuant to the completion of a revised HIV/AIDS reporting instrument, the development of a computerised system for in-country capture of this data is scheduled for early next year.

Mortality Data Issues

The mortality software application, MortBase, was upgraded to accommodate the tenth revision of the International Classification of Diseases (ICD-10). The system was also migrated from FoxPro 2.5 to Microsoft Access 97 in order to assure Y2K compliancy. This new edition of the software was pilot tested in Grenada and Jamaica and is currently being disseminated to member countries on a compact disc. In the absence of a computerised system for capturing ICD-10 mortality data, many countries have been tardy in submitting their mortality data to the division. A significant effort is planned to improve mortality data acquisition in the year 2000.

Internet Utilization

The Division has also increased its utilization of the Internet and its various services as a vehicle for communicating and disseminating information, especially to its member countries. Three countries currently forward their weekly communicable disease reports to us via electronic mail, while we transmit our reports and bulletins to persons in seventeen member countries via the same route. Although there are Internet service providers in all of our member countries, many Ministries of Health still have somewhat restricted access. However, we do anticipate that our member countries would make greater use of the Internet during the year 2000.

Web Services

During 1999, the Epidemiology Division optimized its dissemination of epidemiologic and surveillance data through postings on the CAREC website, www.carec.org, which currently hosts forty-six documents that have been produced by the Division. These postings included the Communicable Diseases Feedback Reports, EpiNotes, Facsimile Alerts and information on AIDS morbidity and mortality. There has been increased utilization of the information provided on our web site as evidenced by the number of requests for data being received by the Organization’s Webmaster.

Year 2000 (Y2K) Issues

During 1999, the Division’s systems analysts were involved in a series of activities to ensure that all of our computers as well as the propriety software and applications developed by the Division were made Y2K compliant. In this regard, some computers were replaced, while several software applications were upgraded. Epi Info, MortBase and EPISUMM were among those applications which were upgraded. EPISUMM, the communicable disease-reporting module of CARISURV (Caribbean Surveillance) was reengineered and upgraded from Microsoft Access 2.0 to Access 97.

Power Supply Issues

During the period under review, the Division continued to experience frequent fluctuations in our electrical power supply, which resulted in the loss of documents and corruption of our computer hard drives. It is hoped that these problems will be resolved as the external power supply to the entire campus was improved and an un-interruptable power supply (UPS) purchased and installed for computer hardware in the Division.

French Technical Co-operation Agency Activities

Subsequent to the December 1998 attachment of a medical epidemiologist sponsored by the French Technical Co-operation Agency, the Division has been working with the French departments of the Americas to improve communication and collaboration and to strengthen surveillance for emerging and re-emerging infectious diseases. These efforts have been specifically targeted to those CAREC member countries, that have been identified for priority attention by the Government of France. In order to strengthen and advance this collaboration, members of the Inter-Regional Epidemiology Cluster (CIRE) of the French National Institute for Public Health Surveillance based in Martinique paid an official visit to CAREC in September, 1999.

Arising out of these discussions, it was agreed that data on a core list of diseases would be exchanged between the French territories and CAREC on a quarterly basis through an official channel. These diseases would include yellow fever, dengue fever, malaria, influenza, measles and tuberculosis. It was also decided that the French data would be utilized for constructing regional trends and epidemiologic profiles and would be published in the Communicable Disease Feedback Reports. In October, CAREC was invited to participate in the 1999 CIRE steering committee meeting, which was convened in Basse Terre, Guadeloupe.

In order to strengthen the surveillance capacity of the French priority territories belonging to the Organisation of Eastern Caribbean States (OECS), a project proposal was developed and submitted for funding to the French Technical Co-operation Agency during 1999. The specific purpose of this project is to enhance the capacity and infrastructure for epidemiological surveillance in order to ensure early case detection and efficient public health responses to the emerging and re-emerging infectious diseases (EIDs) and other diseases of special interest to the Caribbean.

Suriname, a CAREC member country, has also been identified for priority attention by the Government of France. As both French Guiana and Suriname are contiguous parts of the Guyanese shield, being separated by the Maroni river, they can be exposed to the same infectious disease threats. Outbreaks of cholera in Suriname during 1993 and yellow fever in French Guiana during 1998 are examples of epidemic situations, the effective control of which would have required rapid communication and cooperative action between the two countries. In April 1999, an Epidemiology Division team visited Suriname to jointly identify with the health authorities those EIDs for priority surveillance and to discuss possible avenues for technical co-operation activities with French Guiana, in order to strengthen disease surveillance and control along the Maroni river. The "Roll Back Malaria" programme was also identified as a priority by both countries and CAREC is ready to undertake follow up of those activities that are planned as a result of the border meetings.

The FTC consultant has been fully integrated into the Division’s activities and is a member of the team, which produces the feedback reports and fax alerts and provides epidemiologic expertise for workshops and technical meetings. Responsibility for monitoring the trends in emerging and re-emerging diseases has been assigned to this officer. This consultant was the main epidemiologist undertaking an investigation of leptospirosis/hepatitis A in Belize during 1999.

Appendix 1
Annual Cumulative Totals of Reported Cases1 of Communicable Diseases with Incidence Rates per 100,000 Population for CAREC Member Countries, 1998–1999

¹These data are provisional and reflect reports received as at 22nd February, 2000.

²The AIDS case data for weeks 1–52 of 1999 are from only fifteen CAREC member countries.

³Total annual births were used as the demoninator for these rate calculations.

⁴Total annual births were subtracted from the total populations and used for this rate calculation.

Note: The demoninator used for the rate calculation reflects the sum of the populations of those CMCs reporting that condition.

Collaborative Linkages

During 1999, the Epidemiology Division continued to work collaboratively with the PAHO Office responsible for Caribbean Programme Co-ordination (CPC) on a number of initiatives in the areas of disaster response, chronic disease and health promotion and human resource development. Financial and technical linkages were maintained with the Walter Reed Army Institute of Research as we further developed the public health laboratory information system. Our relationship with the US CDC and Emory University continued as we worked with Dr. Philip Brachman to produce the communicable disease surveillance manual for the region.

In October 1999, pursuant to a request from the Minister of Health in Trinidad and Tobago and in association with the office of the PAHO/WHO Country Representative, a CAREC epidemiologist worked collaboratively with an industrial hygienist from the US National Institute of Occupational Safety and Health (NIOSH) in an effort to resolve a series of problems, which had developed in relation to asbestos in schools and health facilities in Trinidad and Tobago.

Notes Related to Appendix 1

The data presented in Appendix 1 should be interpreted with the following in mind:

1. The 1999 data on acute haemorrhagic conjunctivitis may be an underestimate as cases reported to us as viral or acute conjunctivitis were not included.

2. Complete communicable disease data has not been available from Guyana over the period 1998–1999 and, hence, the cumulative totals for certain diseases such as tuberculosis and malaria would be higher than our data suggests.

3. Acute Respiratory Infections among under fives are not under surveillance in seven CMCs.

4. Only six CMCs are currently reporting data on genital syndromes.

5. Data on gastroenteritis from Trinidad and Tobago is not provided in an age-categorized format and have, therefore, been excluded from the age-specific sub-regional totals. However, 19,796 cases of gastroenteritis were cumulatively reported from that country during 1999.

6. No AIDS Surveillance Reports were received from three CMCs in 1999. Outstanding AIDS reports for 1998 and 1999 have now been received from Trinidad and Tobago and are included in our cumulative totals.

Caribbean Epidemiology Centre
16-18 Jamaica Boulevard, Federation Park
P.O. Box 164, Port of Spain
Republic of Trinidad and Tobago
Tel: (868) 622-4261, Fax: (868) 622-2792
E-mail: postmaster@carec.paho.org

Page last modified 04 July, 2001