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1998 Annual Report
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 | Epidemiologic field investigations of five outbreaks were successfully undertaken in
collaboration with staff from our member countries, other internal CAREC Divisions and
external agencies, with the consequent addition of valuable new information pertinent to
disease prevention and control. |
| Dissemination of epidemiologic and surveillance data was enhanced through postings on
CAREC’s website; the publication of quarterly feedback reports, fax alerts and
EpiNotes; and presentations at a number of regional and international meetings |
| The knowledge and skills of various health professionals in our member countries were enhanced through a number of training initiatives in the areas of epidemiology, outbreak investigation, research methodology and statistics. |
| Closer communication and collaborative linkages were forged between the Epidemiology and
Laboratory Divisions in support of enhanced disease prevention and control. |
| Our capacity to construct more complete epidemiologic disease profiles was expanded as
electronic access to CAREC’s laboratory database through the newly created laboratory
information system [LABIS] was possible for the first time. |
| Our thrust in health information systems development was expanded as a public health
laboratory information system [PHLIS] was customised for the Caribbean. |
| A landmark document entitled "A Caribbean Communicable Disease Public Health
Surveillance Manual for Action" was produced for use in our member countries. |
Pursuant to our major mandate for surveillance of communicable diseases in the sub-region, the Division has continued to work collaboratively with our member countries to improve the quality, reliability and timeliness of data generated at the national level. Following receipt of these reports, the data are consolidated into a regional database, EPISUM, (EPISUM is a module of CARISURV), the Centre’s umbrella surveillance system which consists of several established and evolving modules from which it is analysed, interpreted and appropriate reports, such as the Communicable Diseases Feedback Report, generated.
We note with pleasure that the quality of the weekly communicable disease reports has continued to improve as evidenced by fewer inconsistencies and inaccuracies and we wish to congratulate our member countries for this important development. We, must, however, indicate that there is still need for improved timeliness so as to enable us to define emerging sub-regional trends earlier, and hence, be better positioned to influence public health actions.
In addition, more of our member countries have begun to produce their own surveillance bulletins, and we view this development as a positive indication that the message of providing feedback as an essential step in the surveillance process has taken root.
Both CAREC members as well as non-member countries of the sub-region continued to be apprised of changing communicable disease situations through our Communicable Diseases Feedback Reports, Fax Alerts and EpiNotes. Other types of epidemiologic reviews for example, "Caribbean Demographic and Health Trends: Social and Economic Implications for the Twenty First Century", have been periodically disseminated. The further development of the CAREC web site has greatly facilitated more extensive dissemination of information, including sub-regional morbidity and mortality data on Acquired Immunodeficiency Syndrome.
Pursuant to our role in assisting member countries to strengthen their communicable disease surveillance systems, monitoring and evaluation of these national systems constitute an ongoing activity of the Division. A multidisciplinary CAREC team visited Aruba in 1998 and based on its findings, recommendations were made to facilitate the implementation of a system and the conduct of communicable disease surveillance in that country. An evaluation of the communicable disease surveillance system was also undertaken in Belize as part of our assessment of their response to Hurricane Mitch. Our findings indicated that a number of weaknesses existed and that there was urgent need for clarification of the roles and responsibilities of the National Epidemiologist. In addition, training was urgently required both at the central and district levels in order to strengthen their capacity to respond to epidemiologic issues. Our planned 1998 visits to Anguilla and the Netherlands Antilles had to be postponed for various reasons, which were beyond our control.
Based on our recent evaluations of communicable disease surveillance systems in our member countries, and pursuant to specific requests from our National Epidemiologists, it is with pride that we report that a generic manual on communicable disease surveillance was produced in 1998. This document is currently being circulated on a limited basis for comment, prior to editing. We view the production of this manual at this time to be critical, as many of our member countries are involved in health sector reform, one consequence of which is the devolution of the responsibility for surveillance to apparently autonomous health districts and regions. Funding for this project was made available to us from the Fogarty International Institute.
During 1998, our Division actively sought to strengthen its partnership with the Laboratory Division in support of enhanced disease prevention and control. One of our Epidemiologists has been assigned the responsibility for liaising with the laboratory and for establishing ongoing and consistent information exchange. During 1998, we worked collaboratively to further refine guidelines for the surveillance of dengue fever. A multidisciplinary dengue fever task force was convened in order to provide an internal forum for achieving consensus on issues related to epidemiologic surveillance; laboratory diagnosis; vector surveillance and control; community participation in vector control; and clinical case management. The operations of the laboratory information system [LABIS] have provided us for the first time, with access to timely data that enhances our ability to construct more real-time epidemiologic profiles.
Of those diseases subject to the International Health Regulations, only cholera was reported in the sub-region during 1998, and exclusively so from Belize. A real decline was noted in the reported incidence of rubella and congenital rubella syndrome in the sub-region [Epidemiology Appendix 1: Annual Cumulative Totals of Reported Cases of Communicable Diseases- 1997 and 1998], while significantly more cases of foodborne illness, salmonellosis and shigellosis were notified during 1998, as compared with the previous year. During 1998, more than 12,000 cases of acute haemorrhagic conjunctivitis were recorded for a sub-regional incidence rate of 207 cases per 100,000 population. This represented a marked increase over the 1997 incidence rate of 64 cases per 100,000 population.
In 1998, there was a notable increase in reported dengue viral infections across the sub-region as evidenced by a provisional year-end incidence rate of 101 cases per 100,000 population as compared with a 1997 rate of 60 cases [Epidemiology Figure 1]. Following the identification of dengue virus type 3 in Belize in late 1997, fairly spread of this specific virus type was observed through Puerto Rico, Jamaica,
Barbados and St Kitts and Nevis during 1998 [Epidemiology Figure 2]. Of added concern, is the emergence of hyperendemicity in some of our member countries such as Barbados and Trinidad and Tobago. During 1998, all four dengue serotypes were identified from Barbados.
During 1998, there was continued implementation of the IDRC-funded Caribbean hospital-based Injury Surveillance System Project. The development of appropriate software to facilitate data entry, processing and report generation was completed and training and reference manuals were being refined. Additional assistance with this initiative was being provided by a Fulbright Fellow, who is on attachment to the Centre for a ten- month period. The implementation of this project at the first pilot site, the Princess Margaret Hospital in the Bahamas, has generated several lessons for improvement of the system, both from a technical as well as an administrative standpoint. The other pilot sites, Trinidad and Tobago and Barbados are now in the process of reviewing the instrument to achieve internal consensus on its structure, its content and the logistics of its administration. The Ministry of Health in Jamaica has expressed interest in being included as a pilot site.
Two staff members attended the Fourth World Injury Conference and the Meeting of the WHO Injury Surveillance Methodology Workgroup in April 1998. A first draft of the International Classification of External Causes of Injury [ICECI] was introduced at this meeting. Based on the experience gained from developing classification schemes for the Caribbean project, the CAREC associates were able to contribute practical comments for refinement of that document. A small working group meeting was convened at the US CDC in October, to further refine the ICECI document, this being complemented through collaboration with international colleagues in the development of a minimum basic data set for Injury Surveillance. Through this hospital based Injury Surveillance System and its flexible software, CAREC and its pilot sites, would provide an ideal opportunity for testing of the ICECI and validating it against the International Classification of Diseases [10], especially in developing countries.
In October 1998, staff of CAREC and the PAHO-CPC’s Office met to formulate a work plan for the implementation of non-communicable disease surveillance in the Caribbean. During this working meeting which was facilitated by a Consultant of the US CDC, diabetes, injuries and the cancers of the breast, the uterine cervix and the prostate were selected as the conditions for surveillance. Currently available sources of data suitable for surveillance purposes were considered. While it was recognised that mortality data systems do exist and provide data on chronic diseases, albeit historical, it was proposed that existing morbidity data systems [hospital patient registration, health centre chronic disease clinic records, disease registries] be utilised to generate relevant information. It was also proposed that behavioural risk factor data, collected through surveys to be conducted in CAREC member countries, should complement existing mortality and morbidity data, thus providing more real-time information. While it is envisaged that initially, four different countries, representative of our members, will be targeted for the collection of sub-regional data, the instrument and protocol to be developed may be used by individual CMCs to describe their national situations. A proposal is being drafted for circulation and comment. It has also been proposed that anonymous life insurance data may be used as a surrogate for ongoing surveillance of the working population.
The resurgence of tuberculosis in the sub-region demands renewed political commitment in order to ensure that appropriate mechanisms are established for effective management and control of tuberculosis. In this regard, we note with pleasure that at the meeting of the Council for Human and Social Development [COHSOD] in 1998, the CARICOM Ministers of Health agreed to intensify surveillance for tuberculosis in their respective countries and to fully implement the directly observed therapy-shortcourse strategy, DOTS. Enhanced surveillance and the implementation of DOTS are among those essential components required for effective management of tuberculosis.
In an effort to further strengthen national tuberculosis control programmes, a clear identification of their weakness and deficiencies was first required. As a response, our division embarked upon an evaluation exercise, utilising a retrospective cohort analysis approach in Trinidad and Tobago and St. Lucia. The results of these studies will enable us to make rational and focussed recommendations for the improvement of tuberculosis prevention and control programmes. Proposals have been written for the conduct of a number of prospective studies to address some of the technical and management issues related to TB/HIV co-infection in some of our member countries. A feasibility assessment was undertaken in one member country and it is hoped that these studies will commence during 1999.
Health care workers in the Turks and Caicos Islands and the British Virgin Islands benefited from updates on tuberculosis management and control, which were conducted during tuberculosis outbreak investigations in those countries. A workshop on programme management and control was also convened for health care workers in Montserrat, while assistance was provided to the Ministry of Health in Jamaica with the development of a national tuberculosis manual.
Leprosy has been targeted for elimination by the World Health Organization in the year 2000. The elimination target of less than one case per 10,000 population has been achieved in all our member countries, except Suriname where a prevalence rate of 1.7 cases had been reported for 1997.
The Netherlands Leprosy Relief Association [NLR] has continued to extend financial support to Jamaica and St. Lucia through CAREC, while Guyana, Trinidad and Tobago and Suriname have continued to maintain direct bilateral linkages with this agency. Although disability prevention and rehabilitation constitute the major emphases in this programme, countries have been asked to maintain a high index of suspicion and to sustain services for early diagnosis and appropriate therapy in spite of the declining number of new cases in the sub-region.
In response to the occurrence of repeated outbreaks of nosocomial infections in Dominica, a multi-disciplinary CAREC team facilitated the conduct of a workshop on hospital infection control, which was convened by the Ministry of Health. This workshop sought to educate a wider cadre of nurses as it had been noted that staff attrition was negatively impacting on the smooth operation and the sustainability of the national infection control programme.
CAREC’s Epidemiology Division continued to refine its management of the regional databases that it maintains for general communicable diseases, acquired immune deficiency syndrome and mortality.
There was significant improvement in the quality and accuracy of the communicable disease data being sent to CAREC from member countries. More importantly, greater use was being made of this data as the number and sources of external requests for information from the communicable disease database increased significantly in 1998 over pervious years.
One member country responded positively to our encouragement to utilise the electronic mail route for transmission of their weekly communicable disease data to CAREC. It is hoped that this number would increase substantially by the end of 1999.
The Division conducted a comprehensive audit of its communicable disease database, a process that included review and verification of all of the data received from our member countries for the period 1994 through 1997. A communicable disease review is being planned for publication during 1999.
While the overall quality of the AIDS surveillance data continued to improve, the timeliness of these reports from a number of countries, including some with traditionally high reported mortality, gives cause for concern. Personnel changes at the central level of some Ministries of Health have lead to some degree of ambiguity in the roles and responsibilities for AIDS surveillance, while in others there is inadequate human and infra-structural support to process the significantly increased case load. A number of countries have submitted revised AIDS data for previous years thus enabling CAREC to further refine the quality of its database. A revised HIV infection/AIDS case reporting form has been developed and is being pilot-tested prior to dissemination to our member countries.
A standard package of epidemiologic data on AIDS has been agreed upon for general distribution and has been posted on the CAREC website.
Expansion of the Mortality database was severely limited during 1998, as the appropriate software application [MORTBASE] had not been upgraded to accommodate mortality data being coded in accordance with the new ICD 10 format. This upgrading process has however been commenced. Mortality data was received from Guyana for 1995 and this was added to the sub-regional mortality database. Requests for mortality data have also increased markedly. No CAREC-sponsored ICD 10 training was undertaken during 1998 as all of the member countries had benefited from previous workshops.
In-country training programmes were however conducted by national personnel.
During 1998, there was an increased demand for statistical services from CAREC as countries sought to establish and analyse a variety of databases and to generate relevant reports, in support of enhanced surveillance. As a consequence, we responded to numerous requests for training of country personnel in the use and application of Epi Info software. An Epi Info Users’ manual was therefore developed by CAREC’s statistics and epidemiology associates, in order to facilitate these training needs. This manual will constitute the standardized text for introductory Epi Info courses in member countries. Although a first edition has already been utilised at a number of workshops, to date, a revised edition has been produced and will be disseminated during 1999.
CAREC’s statisticians actively supported a number of training activities including a workshop on research methodology, which was sponsored by the Commonwealth Caribbean Health Research Council [CCHRC]. A workshop of similar content was also facilitated for twenty senior research officers of the Ministry of Health, Trinidad and Tobago. The use and application of Epi Info was taught as part of both of these exercises.
In-country training in the use and application of Epi Infosoftware was undertaken for the national AIDS programme in Antigua; the Genitourinary Medicine Clinic of the Ministry of Health in Guyana; the STD services of the Ministry of Health in Barbados; and the Trinidad Public Health Laboratory, the National Surveillance Unit and the national AIDS hotline in Trinidad and Tobago. In general, personnel participating at these exercises were trained in the use of Epi Info for creating questionnaires, data entry, building CHECK files, writing simple programmes [PGM files], data analysis and data retrieval.
Technical input and advice was provided in relation to the analysis of a number of surveys and projects, both internally at CAREC and externally in some of our member countries. In this regard, statistical advice and direct technical assistance were provided for Project SMART Choice and an HIV seroprevalence study among pregnant women in Antigua; and a cancer review project of the National Cancer Registry in Trinidad and Tobago.
Technical oversight for the areas of Health Statistics and Non-communicable Disease Surveillance continued to be provided by the PAHO Bio-Statistician in the Public Health Intelligence Unit.
During 1998, technical assistance in the areas of outbreak investigation, control and management and disaster response was requested of CAREC from a number of our member countries. During these joint exercises with staff from national Ministries of Health, every opportunity was taken to refresh staff as to the principles of outbreak investigation and management, and of the important need to identify and implement appropriate and timely public health actions for effective intervention and control. During 1998, direct in-country field assistance was provided to seven CAREC members, the salient points of which are summarised hereunder:
In January 1998, a multidisciplinary CAREC team visited the Turks and Caicos Islands to assist the Ministry of Health with the conduct on an epidemiologic investigation related to a significant increase in reported tuberculosis morbidity. Twenty suspected cases as well as 19 of 37 potential contacts and 31 health workers were reviewed as part of this investigation. Of the cases investigated, 14 were confirmed as having pulmonary tuberculosis. Of these, one had been inadequately treated for previously diagnosed tuberculosis, while another had defaulted and a third had stopped treatment after two months. Of the contacts traced, two were found to be Mantoux test positive, while another two had clinical and radiologic evidence of tuberculous disease. Although eight of the screened health workers were found to be Mantoux test positive, no interpretation of these results could be made in the absence of their BCG vaccination histories.
This outbreak exemplified the potential for re-emergence of tuberculosis, through the migration of infected persons from hyper-endemic areas. It also brought into focus the urgent need for the following:
| strengthening of tuberculosis management and control programmes; |
| ensuring that confirmed cases were followed-up and that appropriate treatment regimens were prescribed by the public health authorities and complied with by the patient; |
| implementing Directly Observed Therapy, Short Course in order to promote treatment compliance and to minimise the potential emergence of multi-drug resistant disease; |
| ensuring that there were no barriers to treatment; and |
| ensuring that the laboratory services were capable of providing quality results. |
It was recommended that screening for tuberculosis be included as part of the medical evaluation of immigrant workers and their families, arriving from countries with a high prevalence of tuberculosis.
In February 1998, CAREC’s Epidemiology and Laboratory Divisions supported the Ministry of Health, Bermuda, with the conduct of an extensive epidemiologic and environmental investigation of an outbreak of gastrointestinal illness at one of the country’s large hotels. Over four hundred cases of gastroenteritis were documented in this outbreak and these included hotel staff, hotel guests as well as other hotel patrons who were not in-house guests. The hotel’s drinking/potable water supply had become contaminated with sewage, and a Norwalk-like virus was identified as the aetiologic agent both in clinical specimens as well as water samples tested by the US Centers for Disease Control and Prevention.
In February 1998, a fatal case of Plasmodium falciparum malaria was notified from the Bahamas. The patient was a 45 year old male Bahamian, whose infection had been classified as imported by the national health authorities. As part of this outbreak investigation, extensive screening surveys, utilising thick and thin film microscopy and immunofluorescent antibody techniques, had been undertaken in populations living in close proximity to this index case. This exercise subsequently yielded four additional cases, all of which were classified as indigenous. It must be emphasised that the potential for re-introduction of malaria with subsequent local transmission, is real in those countries from which this disease had been previously eradicated, as a number of facilitating conditions still obtain. These include, inter alia,
| the presence of competent Anopheline vectors in the sub-region; |
| the high mobility and migration of infected persons from endemic areas within the Caribbean; |
| the political and socio-economic realities and circumstances related to the entry of many of these migrants make the conduct of effective surveillance a challenge for the public health authorities and, hence, do not facilitate either the early diagnosis and treatment of cases or the implementation of timely prevention and control measures. As a result, local malaria transmission could occur and remain undetected for some time. |
Pursuant to a request from the Director of Health Services in the British Virgin Islands, CAREC’s Medical Microbiologist investigated an outbreak of tuberculosis in that member country in July, 1998. This outbreak involved an index case, confirmed by microscopy, and four contacts. Another person, an immigrant from a high endemic tuberculosis area, who was suspected of having pulmonary disease, could not be appropriately evaluated as she refused to comply. Two important issues were identified as a result of this outbreak investigation. Firstly, there appeared to be some confusion as to the indications for implementing treatment vis-a-vis chemoprophylaxis, and secondly, the differences between the American and Caribbean recommendations regarding indications for treatment or prophylaxis are creating some difficulties, especially as BCG vaccination has been and is still being widely administered in our member countries as part of PAHO’s recommended strategies on expanded immunisation.
An investigation into a nosocomial outbreak of gram-negative infections at the neo-natal unit of the Princess Margaret Hospital in May 1998, revealed that 31 babies had been affected between January and May, 1998. Serratia and Klebsiella were the most frequently isolated bacterial pathogens and a review of the antibiograms on 30 of these cases indicated that 83.0 percent of them were resistant to ampicillin. Attack rates by month of birth as well as by month of admission to the neonatal unit were highest during the month of April. The distribution of cases by week of birth revealed that 70.0 percent of them had been born during the fourth week of one month and the first week of the next. Analysis of the data indicated that transmission of infection had occurred both in the delivery area as well as in the neonatal unit.
It was concluded that a combination of factors rather than any single exposure could have contributed to this increase in gram-negative infections. Some of these may have included:
| the lack of use of face masks during delivery and other procedures; |
| loss of potency of the Cidex solution near the end of the month resulting in inadequate disinfection of instruments [Cidex solutions were being changed around the beginning of every month]; |
| cross-contamination from gloves and instruments immersed in the Cidex solution to surfaces and instruments in the delivery and neonatal units; |
| warm ambient temperatures overnight [the central air-conditioning unit for the delivery unit was turned off at nights] would support the multiplication and growth of organisms in the solutions and on contaminated surfaces; and |
| improper cleaning and storage of the resuscitation equipment. |
This outbreak provided ample illustration of the important need to maintain active surveillance for nosocomial infections.
A review of the post-disaster surveillance data for St. Kitts and Nevis indicates that injuries were the major cause of morbidity as measured by visits to hospitals and outpatient facilities. It was estimated that over the period September 20-27, 1998, immediately following Hurricane Georges, 73.0 percent of the reported injuries (273/376) were hurricane related.
In November 1998, two CAREC associates were part of a three-man team that reviewed the response of the health sector in Belize to Hurricane Mitch. We noted, that members of the health team at the district levels had worked tirelessly and with dedication, above and beyond the call of duty, to ensure that 75,000 persons were evacuated, housed and fed for a period of time that was not anticipated, without any fatalities or major casualties. Of major concern, however, was the absence of any epidemiologic surveillance either at the level of the shelters or in the immediate post-recovery period. This review indicated that among other things, there was urgent need for the following:
| the design of a simple disaster surveillance system with appropriate training of relevant staff in the conduct of post-disaster surveillance; |
| clarification of the roles and responsibilities of designated surveillance personnel; |
| education of the public in matters related to environmental health, vector control, etc; |
| more attention to be paid to disaster planning for different hazards and scenarios; and |
| more detailed planning in the important area of shelter management. |
In addition to the above, technical advice and support was provided to member countries for a number of other outbreaks which are listed hereunder:
| Gastroenteritis in Grenada; |
| The occurrence of a hotel associated case of Legionellosis in Curacao; |
| Cryptosporidium contaminated water at a hotel in St. Lucia; |
| Conch poisoning in the Bahamas; |
| Acute haemorrhagic conjunctivitis in a number of member countries; |
| Nosocomial infection at a neonatal unit in Dominica; |
| Meningococcal illnesses in Trinidad and Tobago; |
| Suriname and Guyana received epidemiologic advice pursuant to a fatal case of yellow fever in French Guiana and the subsequent occurrence of cases in Brazil and Venezuela |
| Brucellosis in Trinidad and Tobago
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PHLIS is a PC-based software application, originally developed by the US Centers for Disease Control and Prevention [CDC] for salmonellosis surveillance. It allows for a hierarchical reporting scheme through which data is transmitted from lower level reporting sites to higher level sites. During 1998, technical assistance in the form of equipment and training in PHLIS was provided by the Walter Reed Army Institute of Research [WRAIR] for several member countries. CAREC is being established as the top level site, with the national Public Health Laboratories reporting their data upwards to their respective Ministries of Health and to CAREC. The major aim of this project is to establish a communication network between national laboratories and epidemiologists at the country level, and between the countries and CAREC. CAREC has the responsibility for facilitating the implementation of the system in the sub-region.
Pursuant to its role, staff of the Epidemiology and Laboratory Divisions worked jointly to develop, inter alia, the first PHLIS module on enteric diseases as well as an implementation proposal. One Epidemiology associate received a practical orientation to PHLIS at the US CDC and subsequently conducted in-house training for CAREC staff. A training schedule and materials have also been developed for countries. Establishment of the required infrastructure both at the CAREC and country levels is being pursued. The CDC’s version of PHLIS is being customized for Caribbean use.
It is anticipated that the implementation of PHLIS will strengthen both the national and regional capacity for disease surveillance and control in general, and in particular, emerging infectious disease surveillance and response in the Caribbean.
During 1998, developmental work on this World Bank funded project continued with the Caribbean College of Family Physicians. Further to the stakeholders workshop that was convened during 1997, additional discussions were held with prospective participants in order to arrive at consensus positions re: contractual arrangements for execution of the project. For example, there were differences in opinion as regards the physical location of the computers being provided to the medical practitioners. Purchase orders were placed for the delivery of twenty-three computers. The posts of Epidemiologist/Project coordinator, Systems Analyst and Administrative Assistant were advertised during the latter months of 1998 and prospective candidates were interviewed. It is expected that the successful candidates will commence work early in 1999. This project is very important in so far as it will provide a new source of surveillance data from the private health sector, which will complement other disease data both at the national and regional levels.
During this year, continued efforts were made to improve the timeliness and quality of data received from member countries. Standardized letters and reports were designed and developed to indicate to countries the existence of discrepancies between their reported cumulative totals and ours. Roughly one third of our member countries responded favourably to these reports. Assistance was provided with the production of the quarterly feedback reports. Standardised tables and graphs were developed and automated to improve the quality and timeliness of these key inputs.
The Division has been actively utilising CAREC’s web page as another avenue for disseminating information. Feedback Reports, EpiNotes, Fax Alerts and key epidemiologic data have been posted on the web page and regularly updated. Although our Division usually receives and responds to many requests for statistical information from our stakeholders as well as the general public, the load in 1998 was tremendous and further strained our limited resources. In order to manage this very important function efficiently in the future, we have planned to make available through our web page the information most frequently requested in a standardised format.
In order to facilitate the communicable diseases review process for the period, 1994 through 1997, tables were generated and carefully scanned for discrepancies. The yearly counts were converted to an Access database to facilitate easier manipulation of the data.
Both intra and inter-Divisional electronic connectivity were severely compromised during the first six months of the year owing to the relocation of the Epidemiology Division to off-campus sites. The installation of a network to facilitate information sharing and efficient communication was neither logistically nor economically feasible under those conditions. In spite of these obstacles, however, we continued to maintain the many databases for which the Division is responsible.
Epidemiology Division associates were significantly involved with Human Resource Development Adviser of the PAHO-CPC in the development and delivery of a workshop entitled Applications in Health Information Management-level 2. This specific initiative, which was part of a wider human resource development project being funded by the W.K Kellogg Foundation, was intended for middle and upper level health professionals who are required to use information for planning and decision making. Training materials for this workshop were developed by Epidemiology Division associates in the areas of epidemiology, statistics and basic research methodology. An EpiInfo training manual was also created for the workshop.
Workshop participants received a practical orientation to the Internet and to a number of software applications, such as Microsoft Word, Excel, PowerPoint and EpiInfo. Principles of project management, decision making and presentation techniques, epidemiology, statistics and basic research methods were also taught as part of this package. Participants worked on a project of their own choice over a six-week period and presented their findings at the end of this time.
During the year, staff from the Epidemiology Division acted as facilitators in two of these workshops, one in Barbados and the other in British Virgin Islands. In Barbados, they were also part of a team that evaluated this training programme.
Results of the course evaluation questionnaires, pre-test and post-test exercises and the group presentations suggest that the short term impact of the workshop was very positive. Participants’ expectations of this workshop were reportedly satisfied.
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. Support staff participated in training initiatives in the areas of office management, quality customer service and business etiquette. As the Division and the wider organisation prepared to grapple with those issues related to Y2K compliance, our systems analyst attended a seminar on the legal implications of the Year 2000 problems.
The Divisional Manager as well as the systems analyst traveled to Canada on a study-tour which was sponsored by the Canadian Public Health Association as part of its collaboration with CAREC’s CIDA-funded project. The specific purposes of this study tour were to review the conduct of HIV/AIDS surveillance in Canada and its related systems, processes and procedures; to develop an appreciation of the linkages that facilitated the conduct of surveillance between the provincial and federal levels; and to identify any points or issues which could be applied to enhance HIV/AIDS surveillance in the Caribbean sub-region. We noted that some of the barriers to effective HIV/AIDS surveillance in Canada, such as, for example, those related to confidentiality, were similar to those being experienced in the Caribbean. We further noted that their proposed solutions were also greatly similar to ours. The major impacting differences, however, were related to the availability of adequate financial resources in support of surveillance; and very importantly to the widespread availability and access to antiretroviral therapy, the utilisation of which had resulted in a real decline in the annual AIDS incidence rates in Canada.
The technical focal point for tuberculosis attended two international conferences, one in Vancouver, Canada and the other in Bangkok, Thailand. A paper on Enhancing Control Activities for Re-emerging Tuberculosis in CAREC Member Countries was presented at the latter meeting [The Global Congress on Lung Health].
Epidemiologic data is essential to guide decision-making in all aspects of formulating, implementing, monitoring and evaluating health policies and programmes. Every country should have a minimum core of epidemiologic services in order to plan and evaluate their health promotional, preventive and disease control programmes and to monitor progress towards achieving stated goals. These core epidemiologic capabilities are essential if countries are to undertake all or some of the following activities on an on going basis:
| measure indicators of health status and quantify the magnitude of disease problems in the population; |
| evaluate the effectiveness of health service delivery and utilization of health resources; |
| evaluate the effectiveness and the impact of health-promoting and disease-preventing interventions; and |
| disseminate appropriately analysed and interpreted health information in a timely manner to policy-makers and planners so as to influence decision making. |
A Field Epidemiology Training Programme [FETP] is a programme of applied epidemiology training designed to develop the public health capabilities and infrastructure of the country or region in which it functions. FETPs are designed to provide a continuous supply of field-trained epidemiologists who would support a country’s disease prevention and control efforts at the national, regional, and local levels.
The basic tenets of an FETP are:
| that training takes place in the country or region; |
| that the total duration of training be equivalent to at least 2 years of full time work; and |
| that most of the training comprises an apprenticeship or practicum involving epidemiologic problems of public health importance. |
Many FETPs have been modeled after the successful Epidemic Intelligence Service [EIS] which was established in 1951 by the Centers for Disease Control and Prevention [CDC] in the United States.. There are now 21 national/regional FETPs established in the Americas, Australia, Southeast Asia, the Middle East, Europe and Africa. Plans are underway to establish at least three more FETPs before the year 2000.
The Caribbean is ideally positioned to establish a regional FETP to enhance public health training within this sub-region of the Americas. CAREC’s mission does include the building of epidemiologic capacity in the sub-region through training. CAREC’s role in epidemiology and surveillance in the region; the field-based nature of its work; and its public health laboratory altogether make it an excellent training site for field-based public health activities. A regional FETP, if sustained, would represent an efficient and effective means of strengthening the national and regional public health capacity of the Caribbean and CAREC, itself in the long-term.
It would be feasible for a CAREC-based FETP to be linked with well-established FETPs in both the United States and Canada because of their proximity to the Caribbean countries. The University of West Indies [UWI], which currently offers a Master’s degree programme in Public Health, would represent another critical resource for a Caribbean-based FETP. The Caribbean Common Market [CARICOM] provides the political platform for integrating programmes at the level of the Ministers of Health in the region. CAREC has commenced discussions with all of these groups and with the PAHO/WHO country representatives concerning the development of an FETP and a Doctor of Medicine degree in Public Health.
In preparation for the establishment of a regional FETP, CAREC proposes to first build capacity during a pilot phase by training persons to be potential supervisors for future trainees. possible. The experiences of this pilot project may assist in formulating an alternative and less costly model for effectively establishing FETPs in other countries or regions.
The objectives of this pilot project are
| to develop capacity in the Caribbean to supervise FETP trainees; |
| to evaluate the suitability of a regional FETP within a Caribbean context; |
| to evaluate the sustainability of a regional Caribbean FETP; and |
| to provide feedback to global FETP Network on an alternative model for establishing a FETP |
In order to build capacity to supervise FETP trainees, CAREC proposes to select one candidate to complete the EIS program in the United States during 1999-2001. Further, CAREC proposes to offer a set of 5 training modules (6 weeks in total) in 1999-2000 in the Caribbean to three other suitable candidates. Some of these modules will also be used by CAREC to provide training opportunities for other public health personnel in the region.
During 1998, the Epidemiology Division continued to work closely with the Expanded Programme on Immunization [EPI]. The surveillance system for congenital rubella syndrome (CRS) which was developed during the previous year continued with 9 cases having been notified through it. In November 1998, an expert committee consisting of persons from the EPI at PAHO’s headquarters; the US Centers for Disease Control and Prevention; the EPI, Epidemiology and Laboratory Divisions of CAREC met to refine the CRS surveillance systems and to develop an integrated measles- rubella surveillance system for the Caribbean. These refined proposals were presented to the annual meeting of Caribbean EPI Managers which was convened in Grenada during December 1998.
During 1998, the Epidemiology Division continued to work collaboratively with the PAHO Office responsible for Caribbean Program Coordination [CPC] on a number of initiatives. One of these initiatives focussed on the development of goals and targets for the priority area related to the prevention and control of communicable diseases within the Caribbean Cooperation in Health- Initiative II. Staff of CAREC’s Public Health Intelligence Unit and its Epidemiology Division worked collaboratively with PAHO’s Regional Advisers on Chronic Diseases and Health Promotion to develop a plan of action for surveillance of chronic, non-communicable diseases in the Caribbean.
CAREC continued to be an active member of PAHO’s Caribbean Disaster Response Team, co-ordination for which is provided from the office of the CPC, providing technical assistance to St. Kitts/Nevis following Hurricane Georges and to Belize, subsequent to Hurricane Mitch.
Epidemiology Division staff worked closely with the office of the PAHO CPC and the Barbados Community College in the development of curricula and in the teaching of a number of courses in the areas of Epidemiology and Biostatistics as part of a wider programme on Health Information Management, which was coordinated by the CPC’s Human Resource Development Adviser.
Epidemiology Division staff also developed communication and technical linkages with the French Overseas Departments through the Inter-regional Epidemiology Cluster [CIRE]. Our Communicable Diseases Feedback reports as well as Fax Alerts were shared with them, while they in turn forwarded their communicable diseases data to the Epidemiology Division. In June 1998, a CAREC Epidemiologist, the Entomologist and the Medical Virologist participated in a workshop on the prevention and control of dengue fever which was held for a multidisciplinary group of persons, including Clinicians, Epidemiologists, Virologists, Entomologists from Guadeloupe, Martinique and French Guyana.
Epidemiology Division staff continued to work with collaborators from the Walter Reed Army Institute of Research in the United States on the public health laboratory information system.
The data presented in Appendix 1 should be interpreted with the following in mind:
| The data presented in Appendix 1 are based on the weekly communicable disease reports submitted to CAREC’s Epidemiology Division from its member countries. |
| No AIDS surveillance reports have been received from six member countries for 1998 and fourth quarter reports will only become due at the end of February 1999. |
| Data on gastroenteritis from Trinidad and Tobago are not provided in an age-categorised format and have therefore been excluded from the age specific sub- regional totals. During 1998, however, 14,109 cases of gastroenteritis were cumulatively reported from that country. |
| There is no unusual epidemiologic situation as regards malaria in the sub-region. Although our 1997 database did not contain any data on malaria from Guyana, 10,805 cases have been notified for 1998. It should also be noted that no surveillance reports have been received from Suriname, so that our 1998 total does not include cases of malaria occurring there. |
| Acute respiratory infections among under fives are not under surveillance in four CMCs. |
| During 1998, genital syndromes were notified from four member countries, with one country contributing nearly all of the case reports |
| DISEASES | CUMULATIVE CASES | INCIDENCE RATES | ||
|---|---|---|---|---|
| 1997 | 1998 | 1997 | 1998 | |
| Acquired Immunodeficiency Syndrome, AIDS2 | 1450 | 885 | 24.7 | 19.3 |
| Acute Flaccid Paralysis | 15 | 18 | <1 | <1 |
| Acute Haemorrhagic Conjunctivitis | 1423 | 12795 | 63.4 | 207.4 |
| Acute Respiratory Infection (< 5 yrs. old) | 20163 | 19165 | 3122.3 | 2975.2 |
| Chlamydial Infection | 426 | 555 | 51.9 | 77.5 |
| Cholera | 2 | 28 | 0.0 | <1 |
| Ciguatera Poisoning | 517 | 605 | 7.9 | 9.8 |
| Congenital Rubella Syndrome | 23 | 7 | <1 | <1 |
| Congenital Syphilis | 34 | 37 | <1 | 1.0 |
| Dengue Fever | 3940 | 6678 | 60.2 | 101.2 |
| Dengue Haemorrhagic Fever/Shock Syndrome | 95 | 149 | 4.7 | 6.8 |
| Diphtheria | 0 | 0 | 0.0 | 0.0 |
| Food-borne Illness | 1576 | 1885 | 24.1 | 30.6 |
| Gastro-enteritis (<5 yrs. old) | 32611 | 18110 | 5778.9 | 3538.5 |
| Gastro-enteritis (³ 5yrs. old) | 14586 | 12041 | 344.9 | 292.5 |
| Genital Discharge Syndrome | 156 | 23922 | 5.5 | 802.5 |
| Genital Ulcer Syndrome | 627 | 1629 | 22.4 | 55.0 |
| Gonococcal Infections | 1432 | 1186 | 22.8 | 20.1 |
| Influenza | 49122 | 46921 | 750.4 | 760.7 |
| Leprosy (or Hansen's Disease) | 49 | 55 | <1 | <1 |
| Leptospirosis | 310 | 369 | 4.7 | 6.0 |
| Malaria | 5126 | 12756 | 78.3 | 206.8 |
| Measles (Suspected Cases) | 1012 | 516 | 15.6 | 7.9 |
| Meningitis | 124 | 134 | 7.3 | 7.4 |
| Meningococcal Infection (Neisseria meningitidis) | 17 | 23 | <1 | <1 |
| Mumps | 396 | 97 | 6.3 | 1.6 |
| Pertussis (or Whooping cough) | 14 | 5 | <1 | <1 |
| Plague | 0 | 0 | 0.0 | 0.0 |
| Poliomyelitis, acute | 0 | 0 | 0.0 | 0.0 |
| Rabies in man | 1 | 0 | 0.0 | 0.0 |
| Rubella (German Measles) | 603 | 47 | 9.2 | <1 |
| Salmonellosis | 219 | 356 | 4.7 | 5.9 |
| Scabies | 7040 | 6714 | 112.7 | 134.3 |
| Shigellosis | 94 | 194 | 1.5 | 3.2 |
| Syphilis | 1972 | 1786 | 30.1 | 29.0 |
| Tetanus (excluding neonatal) | 8 | 14 | <1 | <1 |
| Tetanus Neonatorum | 0 | 1 | 0.0 | 0.0 |
| Tuberculosis - All forms | 785 | 506 | 12.0 | 8.2 |
| Typhoid Fever | 155 | 111 | 2.4 | 1.8 |
| Viral Encephalitis | 9 | 7 | <1 | <1 |
| Viral Hepatitis - A | 293 | 379 | 4.8 | 6.6 |
| Viral Hepatitis - B | 383 | 403 | 6.2 | 7.0 |
| Viral Hepatitis - Unspecified | 234 | 217 | 3.6 | 3.5 |
| Yellow fever - urban | 0 | 0 | 0.0 | 0.0 |
| 1 The AIDS case data for 1998 does not include reports from six member countries. | ||||
| 2 These data are provisional and reflect reports received as at 31st January 1999. | ||||
| Note: The denominator used for the rate calculation reflects the sum of the populations of those CMCs reporting that condition. | ||||
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Caribbean Epidemiology Centre Page last modified 11 November, 1999 |