1998 Annual Report
Director’s Report
Introduction
Nineteen ninety-eight was the twenty-fourth year of operation of the Caribbean
Epidemiology Centre (CAREC), and the third year of a transformation exercise, the goals of
which are to improve the Centre’s relevance and services to member countries, to
strengthen financial health, and to improve the human systems and competencies at the
Centre. Major lines of action in 1998 were organised by categories of Technical
Cooperation, consistent with the strategic and programmatic orientations of the Pan
American Health Organization (PAHO), for the period 1995-1998; the Caribbean Cooperation
in Health Initiative (CCH); CAREC’s multilateral agreement and its 1998-1999 biennial
plan, together with guidance from its Council and Scientific Advisory Committee.
In the past year, the health situation has become more complex, both in terms of the
emergence of new health problems, diseases and risks, and the hurricane of change in the
health sector, consequent upon health sector reforms, the latter posing both a threat and
opportunity for public health.
New mortality analyses, 1980-1995, show that since 1990, after decades of decline,
mortality rates from communicable disease have been on the rise, with AIDS now being the
major cause of death in males and females aged 15-44 yr. On the other hand, mortality from
diabetes, violence and injuries also increased markedly over the same period.
Emerging/re-emerging disease (EID) problems have also increased, with significant human
and economic impact, particularly given the tourism dependent nature of Caribbean
economies, e.g., dengue and dengue haemorrhagic fever, malaria, tuberculosis (TB), and
food and water borne diseases.
Economically, the Caribbean's dependence on tourism continued to grow, while health and
disease problems in some destinations caused large revenue losses. Our host Country,
Trinidad and Tobago, struggled with a major fall in the price of oil. The Eastern
Caribbean faced a major threat to their banana industry, with the ongoing World Trade
Organisation (WTO) negotiations, and will likely have to transition their economies to
tourism and other areas of activity. There was continued degradation of the physical
environment, with growing concern over global climate trends, while two very damaging
hurricanes and an ongoing volcanic eruption reminded all of the turbulent nature of the
Caribbean.
A more inclusive CCH phase 2 (CCH-2) has begun, recognising the primacy of the
health promotion approach. Under CCH-2, the Centre has particular responsibility for
disease prevention and control, and the building of epidemiologic capacity and
surveillance systems responsive to the health situation.
The new CARICOM Council on Human and Social Development (COHSOD) had its first meeting
in April in Jamaica, within a broader environment that is rapidly evolving
technologically, financially, and politically. Following presentations on the health
status of the Caribbean by CAREC/PAHO/CFNI/UNAIDS, the COHSOD resolved, inter alia, to
eliminate rubella and Congenital Rubella Syndrome; to an expanded intersectoral response
to HIV/AIDS/STD; to reverse the upward trend in TB; and to a campaign on diet and health.
Since then, new evidence has emerged on the use of anti-retrovirals to prevent mother to
child (MTCT) HIV transmission.
Technical cooperation
The body of the annual report describes the impact of the work of CAREC’s
Divisions and Programmes in service, training, and research. Some of the highlights and
innovations are summarized below by focus of technical cooperation and the implications
for countries and the Centre discussed.
Major achievements
Major achievements include the resolutions of the COHSOD; development of goals and
indicators for disease prevention and control; maintenance of the region’s polio- and
measles-free status; successful in-country investigation of five outbreaks; mobilisation
of new financial partners to help address important problems; improving country access to
CAREC databases and the Internet through training and equipment; improved use of
laboratory information in surveillance and decreased turnaround time for results through
fuller implementation of the CARISURV-LABIS system; implementation of new surveillance
systems - injury surveillance in the Bahamas, and the start of a laboratory surveillance
network; the successful pilot of a distance education program in laboratory Quality
Assurance; and much greater involvement of marginalised groups, e.g., sex workers, Men who
have sex with men (MSM), People Living with AIDS (PLHA), in the fight against HIV/AIDS.
Major challenges during the year included the limitations of the aging physical plant
and accommodation, the pressure on the core budget, vacancies in certain key posts, and
managing the high level of donor agency interest and projects.
Resource Mobilisation
In an effort to achieve the mission of the Centre, the mobilisation of new financial,
human, and information resources, and the formation of partnerships was vigorously
pursued. Quota collections in the amount of $US1.57 million were received from 19
countries. This continues the trend of the previous two years of strong support from
member countries, which has helped to attract a high level of donor and external agency
interest in the Centre. Although member countries have paid their quotas well over the
last three years, there had been no increase in the quota budgets since 1995. However, in
September, the Caucus of Health Ministers, following a presentation on the work of the
Centre by the Director, CAREC, approved a 3% increase in the quota budgets, pending the
outcome of the review of regional health institutions, which it is hoped will begin in
1999. This modest increase in the quota budget is most welcome, as this is the main source
of funding of the core work of outbreak investigations and reference services provided to
CMCs.
Extra-budgetary funding amounted to 35% of the operational budget, through a total of
ten grants and agreements. Grants were signed in June and October with the World Bank, Info-Dev
Division, and the UK Dept. for International Development (DFID), respectively. The former
(2 yr., $250,000) will support the establishment of a computerized physician sentinel
surveillance system, initially in Jamaica, St Lucia and Trinidad and Tobago, in
partnership with the Caribbean College of Family Physicians (CCFP). The latter will
support a project on the prevention and control of HIV/STD in CARICOM countries. A
complementary HIV/STD proposal for the UK dependent territories was also developed and
submitted to DFID. CAREC also provided significant input into the design of regional
project on HIV/AIDS prevention to be funded by the European Union, which, is intended to
increase, from one to six, the range of Caribbean organisations involved in the effort.
In March, the CARIFORUM Ministers, meeting in Port of Spain, approved our project on
Strengthening of Medical Laboratories in the Caribbean for $ECU 8.5 million of funding,
and negotiations to finalise this are continuing. In October, the Multilateral Investment
Fund of the Inter American Devlopment Bank approved $US1.3 million towards a
"Caribbean Tourism, Health, Safety and Resource Conservation Project" to be
implemented jointly by CAREC and the Caribbean Action on Sustainable Tourism (CAST), a
subsidiary of the Caribbean Hotel Association. Detailed contractual negotiations with CAST
are nearly completed. These two developments are the fruit of much effort in advocacy and
negotiation, thus adding further value to the membership of the Centre. The support from
these new grants will complement the support of our existing financial and technical
partners as shown in our stakeholders chart.
Direct Technical Cooperation
Support was provided in-country by staff of the Centre in the management of five
outbreak situations with consequent addition of valuable new information pertinent to
successful disease prevention and control. These were: a cluster of autochtonous malaria
in Bahamas; an outbreak of TB in Turks and Caicos Islands, a large outbreak of viral
gastroenteritis due to a sewage contaminated water supply at a major hotel in Bermuda; an
outbreak of Dengue and DHF in Trinidad; and an outbreak of nosocomial septicemia in
Dominica. In addition, epidemiologic advice and laboratory support was rendered in eight
other outbreaks. Help was also provided to St Kittsand Nevis after Hurricane Georges, and
to Belize, after Hurricane Mitch, as part of the PAHO Disaster Response team.
Of note during the year was the increased capability for tracking of laboratory data
and quality parameters and enhanced surveillance through improvements in the Laboratory
Information System (LABIS) and in improved methods of alerting individuals inside and
outside of CAREC about potential outbreaks. Improved teamwork between laboratory and
epidemiology also resulted from starting a laboratory surveillance network, using the CDC
Public Health Information System (PHLIS), with support from the Walter Reed Army Institute
of Research.
National TB programmes in seven countries were reviewed and advocacy for improved
efforts conducted. Though subject to a COHSOD resolution, progress in this area has been
hindered by seeming lack of real commitment in many CMCs and lack of resources, in spite
of several attempts to source extra-budgetary funds.
Dissemination of Technical Information
During the year, the communicable disease feedback report and fax alerts were used to
give member countries surveillance feedback and keep them apprised of emerging disease
problems. In the vector control area, community based efforts and competitions were used
to sensitise on dengue prevention and environmental management. Many of the new projects
will increase the range and quality of surveillance information available to countries,
such as the Physician Sentinel project and the PHLIS project.
The Centre’s information and communication infrastructure was further enhanced to
facilitate dissemination of information to member countries, e.g., remote access to the
LAN, full time connection to the Internet and email available to all staff, and further
developments are planned for 1999.
The SPSTD programme made great use of print, radio and television to inform and educate
the populations of the Caribbean on HIV/AIDS prevention. Many of these campaigns were
broadcast live, in collaboration with partners in Ministries of Health and in national and
regional media houses. Also in this area, groundbreaking work continued with the piloting
of HIV/STD prevention interventions with non-Governmental and community based
organisations. These included youth, men who have sex with men, and commercial sex workers
in six countries. Given the nature of HIV/STD, and the stigma and illegality surrounding
some groups, working with NGOs may be only way to realise effective prevention efforts.
Development of Plans and Policies
Healthier public policy was pursued, for example, through advocacy sessions with four
Governments on the human and economic impact of the HIV/AIDS epidemic and on the need for
an expanded response. This has borne tangible fruit in increased resources being allocated
in some countries to the HIV/AIDS programme, as well as intangible benefits, such as an
enhanced profile for health, and an appreciation of the role of health in development.
This approach could usefully be expanded to other key public health problems, such as
traffic injury and seatbelt legislation.
Five countries were assisted to develop new national plans for HIV/STD prevention and
21 country immunisation programmes also benefited from assistance with the development of
annual plans.
A significant development occurred in October when a regional workshop agreed an
interim policy on prevention of maternal to child transmission (MTCT) of HIV through the
use of anti-retroviral therapy in pregnancy and countries will be assisted in 1999 to
develop plans and mobilise resources. This is likely to have a significant impact when
fully rolled out, saving 200-400 lives per year, and avoiding much unecessary health care
costs. It is also an important step in a new thrust of prevention through better care and
support for people with HIV/AIDS.
Planning also began on a chronic disease surveillance system in collaboration with the
CPC office and the CDC.
Training
Training and human resource development continued as part of the Centre’s core
mission. Five countries had skills upgraded in the use of the Epi Info software and
outbreak investigation methodology was taught in 3 countries. Teaching of epidemiology and
statistics was conducted as part of the Kellogg-funded health informatics program at the
Barbados Community College in collaboration with the CPC office.
In order to strengthen public health capacity in the region, a plan was developed for a
pilot Field Epidemiology Training Programme (FETP). This is intended to develop cadre of
public health specialists who are skilled in the application of a range of public health
disciplines to contemporary health problems, and who can help provide more public health
leadership in the health sector reform process. Seed resources worth $200,000 have been
agreed with CDC and LCDC to start the programme, while more substantial funds are being
sought. The Caribbean programme will be linked to the established FETPs of CDC and LCDC. A
2-3 year foundation period is envisaged during which potential supervisors will be
identified and trained, and the academic modules (five courses) developed, in
collaboration with UWI and others.
A distance education project was piloted in nine CMCs in collaboration with CDC. The
first module, in laboratory quality assurance, made use of five videos developed through a
cost effective alliance with the local television industry, and also using the UWIDITE
system. This will be evaluated in early 1999 and will inform the CAREC master plan for
distance learning.
Regional capacity in vector identification and control was enhanced through a series of
courses at CAREC and in country.
Applied Research
Providing information to guide public health is a main goal of this component, through
studies on health needs, disease risk factors, and on the effectiveness of interventions.
HTLV-1 research continued in collaboration with the Medical Research Foundation, e.g.,
a natural history and pathogenesis study of Adult T-Cell Leukemia, which has reached the
halfway in subject recruitment. Notable HIV-related research was the completion of a
descriptive study of men who have sex with men in six countries, which showed a high
prevalence of unprotected sex, and provides the basis of planning a peer education health
promotion intervention.
A descriptive and case control study of the epidemiology of S. enteritidis was
commenced in collaboration with UWI and CDC in Trinidad and Tobago, Barbados, and Jamaica.
Initial results from Trinidad & Tobago point to raw or partially cooked eggs being the
source on infection.
A study of the prevalence and determinants of seatbelt use among 2,000 plus drivers in
Trinidad and Tobago was conducted in collaboration with UWI Department of Community Health
using methodology that can be replicated elsewhere. Only 42% of drivers and 30% of front
seat passengers were wearing seatbelts, indicating much scope for preventing death and
injuries, and avoiding health care costs through enforcement and promotion of the law.
Results were publicised via the media in Trinidad and Tobago over the Christmas period.
In the vector control area, baseline filariasis studies were completed in two
countries, which provides a potential model for certification of elimination in other
countries. Chagas disease prevalence was measured in three countries. A case control study
of DHF was done in Trinidad and Tobago, which showed that significant environmental
management changes only occurred in homes where someone had died of DHF. Limited
effectiveness of dynafoggers in controlling Aedes was demonstrated in Trinidad and
Tobago, pointing out yet again the need for greater community involvement in control
efforts.
Antimicrobial resistance of enteric pathogens is being studied in six countries in
collaboration with LCDC and PAHO, providing information to help guide treatment. The
gonococcal anti-microbial susceptibility study continued. Dengue PCR was shown to compare
favourably to viral isolation, and has the advantage of speed in the identification of
serotypes.
Management of the Centre
The Centre continued the transformation began in 1996, with the goals of improving
relevance and service to member countries, improving financial health, and developing a
staff more competent in the technical and people skills necessary for effective function
in today's environment.
In terms of the first goal, the range of services and surveillance systems provided
through the Centre is now more relevant to the current health situation in member
countries. Most of the results set in projects were achieved, although a tendency was
noted for the overestimation of what is achievable in a given time. Outbreak management
assistance was particularly valued, and directly related to the approval of the 3%
increase in the quota budgets by Ministers.
Given the health situation, the main gaps include chronic disease and behavioural risk
factor surveillance to inform health promotion campaigns. Planning for these is underway.
Second, given the range and amount of surveillance, evaluation and applied research
information that is generated by the Centre's programmes, there is much room for
improvement of service to CMCs through more regular and effective feedback to a variety of
publics. There is also much scope for helping countries increase the use of available
information. Third, although much training is conducted, there is a need for a plan and
program of training to build capacity, particularly in applied epidemiology.
Physical plant issues adversely affected activities during the year. A major difficulty
occurred when staff in the Epidemiology building had to be relocated off-campus for six
months to permit renovation of the roof, rewiring, and asbestos removal. This included
staff from Epidemiology, Statistics, Human resource, Healthy Hotels, and the Public Health
Intelligence unit. A continuing concern during the year was our inability to pursue
renovations to create an appropriate facility for surveillance of emerging viruses,
including animal innoculation, due to lack of budgetary allocation for such, and the
failure to date of several efforts to access extra-budgetary support for this purpose.
In December we experienced a major problem with leaking over the main block of the
Centre, which houses much of administration and some laboratories, following an attempt to
repair the roof. This problem is not yet resolved and many functions have had to be
relocated to the training laboratory and lecture theatre, while the funding and support is
sought for the construction of a roof over the main block. Staff are to be commended for
their tolerance and flexibility in coping with this situation, which has slowed down the
issuing of some test results.
These situations highlighted the overall issue of the shortage of accommodation for all
the projects coming on stream, as well as the main plant being over 60 years old. In 1999,
it is intended to update and re-cost the master plan, prepared in 1992, and to begin a
capital drive.
With respect to the financial situation, the quota budget continued to perform well,
with 19/21 countries having paid 93% of the assessed quotas as detailed in the
Administration Manager’s report. The PAHO regular funds continued with no increase,
although a successful over the ceiling request for building works augmented the budgeted
amount. Two new grants worth $1.5 million were signed and several others are in the
pipeline.
The staff at the Centre continued to give of their best in a situation where the
demands exceed available resources. The Human Resource Department also increased the range
and quality of services provided thus improving organisational effectiveness. Staffing at
the Centre was at near full complement, but key vacancies existed that hindered technical
cooperation. Among the PAHO staff, the Epidemiologist acted and was then confirmed as
Director, CAREC in August. The Virologist post was vacant from the end of June and this
impacted negatively on the progress of virology and molecular biology. Towards the end of
the year, part time assistance was arranged with the previous virologist (now retired) to
provide some support while the position is being filled.
Among the CAREC staff, vacancies in the virology, information technology, and materials
management were not filled, indicating the shortage of these skills in this market as well
as the competitive nature of the Information Technology market. In this regard, CAREC
staff benefits are still not on par with the agreed comparator, CARICOM, and this needs to
be addressed if we are to be more competitive in attracting and retaining good staff. Much
needed progress was made in strengthening the Epidemiology Division, with the hiring of an
epidemiologist who will focus on laboratory surveillance, and the assignment of an
Epidemiologist from the French Technical Cooperation in June and December, respectively.
Complete implementation of new multi-source feedback staff appraisal system was a
noteworthy achievement and has informed the staff development plan. There was a small
positive increase in average scores in most areas measured between the probationary period
and the second annual appraisal.
Perspectives and Recommendations
The level of outbreak and emergency support required of the Centre by member countries
during the year continued the trend of the previous year, and was markedly different from
earlier years, indicating that changes have occurred in the factors influencing the
occurrence and recognition of outbreaks. The need to meet these demands through increased
staff travel and the purchase of reagents, etc., reduced the allocated amounts for
necessary equipment and infrastructure improvements.
The factors linked to the EID situation include ever-increasing travel;
emergence/re-emergence of pathogens, e.g., Dengue virus type 3 and DHF, TB, S.
enteritidis PT4, brucella, anti-microbial resistant strains, and weakening of
the public health infrastructure. At the same time, the increase in mortality from
diabetes and injuries indicates further changes in the underlying risk factors and
behaviours favouring the emergence of non-communicable disease, and the challenge of
increasing in-equity and poverty in many countries, which together with the drug trade,
for example, fuel conflict.
These situations emphasize the need to strengthen national public health capacity and
the science base for public health, particularly in applied epidemiology, disease
surveillance and response, as outbreaks can have a disproportionate economic impact, given
the tourism-dependent nature of many of our economies. In this regard, a new Caribbean
communicable disease surveillance manual has been prepared with assistance from Emory
School of Public Health and will be used for training in the future. Secondly, the
establishment of the FETP will be vigorously pursued.
In responding to the health challenges, the CCH-2 initiative has agreed to use the
health promotion approach, though exactly how this will be applied to the eight agreed
priorities needs further elaboration. It will likely include more use of advocacy at
national and regional levels to influence healthy public policy, based public health
surveillance information; leveraging the health sector reform process to benefit public
health; supporting healthy behaviour change through information, education and
communication; and the building of alliances with non-traditional partners. It is clear
that the Centre, while maintaining its core purpose of improving the health of Caribbean
people, has been evolving its strategy to a more explicit health promotion approach, in
order to support member countries in responding to the health situation. This will
continue in 1999 and beyond.
Under CCH-2, information to bring about change and to track progress towards objectives
will be key. Recognising the pivotal role of the use of information and Information
Technology in health promotion and disease prevention, greater emphasis was placed on
capacity development in this area during the year, while a multi-disciplinary ICT team
under the D/CAREC was formed to develop the 2000-01 plan. More effective communication to
a range of internal and external publics to improve health, prevent disease and develop
alliances will be a major future emphasis.
Although the new surveillance systems being developed by the Centre will expand the
range of information available to countries, there is a need to integrate surveillance
systems into a more holistic model, particularly for smaller countries. In this regard,
the CARISURV concept will be further developed during 1999, as an umbrella or tree with
many parts or modules, which are connected. This reflects the need for a range of
approaches, tools and instruments needed to measure and track health status and trends in
our populations.
With regard to the financial situation, the short-term outlook is a bit healthier than
in the past, particularly where grants and contracts are concerned. The performance in
this area is directly linked to country support via the quotas. As detailed in my last
Director’s report, the success with grants requires a tremendous effort in
developing, negotiating, managing and reporting on them. A projects unit is needed be more
effective as grants and contracts will continue to increase in importance. With the
multiplicity of financial partners, there is also a need for improved donor coordination
to achieve more synergy, and to free staff of inordinate reporting requirements. Between
the various PAHO, CAREC and donor reporting requirements, the same project can be reported
upon three times, which is wasteful. An important point also is that grant funding tends
to be tied to specific programmes with insufficient overheads being paid to the Centre for
operating expenses, essential maintenance or much needed development work. There is a need
therefore to find sources of uncommitted funds that can be used for these purposes.
To manage the Centre more effectively and to position it to survive and thrive, an
Institutional Strengthening Project will be undertaken with funding from the UK DFID.
The purpose is to further transform the organisation to better meet increased and
changing country needs for service, and to continously respond to the changing
economic, political and technological environment. The project's expected results will
increase the Centre's capacity in three inter-related areas: HR, information and
communication, and improved financial management.
In closing, on a personal note, I would like to thank all those who have supported the
Centre during the year, particularly the staff in Ministries of Health in member
countries, staff at CAREC, staff in PAHO representations and at headquarters, and the
several donor and technical agencies who are our partners.
C. James Hospedales
Director
