Caribbean Public Health Agency Research Articles

Childhood Obesity and the Risk of Hypertension in the Caribbean Region: A Narrative Review

Childhood obesity is a rising epidemic affecting both developed and developing countries worldwide. In the Caribbean, estimates of obesity in children are noted to be above the predicted global values, and evidence suggests that the rise in obesity levels is due to environmental influences in dietary practices and physical inactivity. Methods: This review aims to determine the effects of childhood obesity and the associated risks of developing hypertension in the Caribbean population. Research articles were identified using computer-based search engines such as Google Scholar, PubMed, ScienceDirect, World Health Organization (WHO), and Caribbean Public Health Agency (CARPHA) databases. Researched articles with various study designs were then thoroughly analyzed to extract detailed information about obesity in childhood and the risks for hypertension in later years. Results: Rapid weight gain in infancy and high (body mass index) BMI levels in childhood are associated with higher blood pressure values and increased cardiovascular risk. Additionally, direct baseline elevation of blood pressure (B.P.) measurements, noted in obese/overweight children compared to their nonobese counterparts, confirm the hypothesis that childhood obesity is positively associated with hypertension. Conclusion: This review article provides detailed facts about childhood obesity, the risk for hypertension, and improvement recommendations and calls attention to the health implications of obesity-related hypertension in children if left untreated.

Assessing the Health Security Responsiveness of the Caribbean Public Health Agency (CARPHA) and the Government of Trinidad and Tobago: The Zika and COVID-19 Outbreaks

This article examines the response of the Caribbean Public Health Agency and the government of Trinidad and Tobago against the Zika and COVID-19 outbreaks. These contrasting diseases were chosen to examine the surveillance systems and responses and the preventative public health measures that were implemented to protect the population. Health experts were interviewed and the data were analyzed using thematic analysis. The findings revealed that the Caribbean Public Health Agency and the government of Trinidad and Tobago were prepared to respond to the Zika outbreak. However, there is much to be improved in the case of COVID-19. Concrete policy recommendations are discussed.

Implementation of genomic surveillance of SARS-CoV-2 in the Caribbean: Lessons learned for sustainability in resource-limited settings.

The COVID-19 pandemic highlighted the importance of global genomic surveillance to monitor the emergence and spread of SARS-CoV-2 variants and inform public health decision-making. Until December 2020 there was minimal capacity for viral genomic surveillance in most Caribbean countries. To overcome this constraint, the COVID-19: Infectious disease Molecular epidemiology for PAthogen Control & Tracking (COVID-19 IMPACT) project was implemented to establish rapid SARS-CoV-2 whole genome nanopore sequencing at The University of the West Indies (UWI) in Trinidad and Tobago (T&T) and provide needed SARS-CoV-2 sequencing services for T&T and other Caribbean Public Health Agency Member States (CMS). Using the Oxford Nanopore Technologies MinION sequencing platform and ARTIC network sequencing protocols and bioinformatics pipeline, a total of 3610 SARS-CoV-2 positive RNA samples, received from 17 CMS, were sequenced in-situ during the period December 5th 2020 to December 31st 2021. Ninety-one Pango lineages, including those of five variants of concern (VOC), were identified. Genetic analysis revealed at least 260 introductions to the CMS from other global regions. For each of the 17 CMS, the percentage of reported COVID-19 cases sequenced by the COVID-19 IMPACT laboratory ranged from 0·02% to 3·80% (median = 1·12%). Sequences submitted to GISAID by our study represented 73·3% of all SARS-CoV-2 sequences from the 17 CMS available on the database up to December 31st 2021. Increased staffing, process and infrastructural improvement over the course of the project helped reduce turnaround times for reporting to originating institutions and sequence uploads to GISAID. Insights from our genomic surveillance network in the Caribbean region directly influenced non-pharmaceutical countermeasures in the CMS countries. However, limited availability of associated surveillance and clinical data made it challenging to contextualise the observed SARS-CoV-2 diversity and evolution, highlighting the need for development of infrastructure for collecting and integrating genomic sequencing data and sample-associated metadata.

Cancer registry operations in the Caribbean during the COVID-19 pandemic: a report of lessons learned and opportunities identified to support strong and sustainable health systems

BackgroundPopulation-based cancer registries (PBCRs) are crucial for cancer prevention and control planning. Building and maintaining resilient information systems within cancer registries that enable consistent and uninterrupted operations during public health emergencies is important. We report on the impact of the COVID-19 pandemic on the operations of Caribbean PBCRs, together with opportunities, lessons learned, and strategies to strengthen and sustain PBCR operation and data quality.MethodsThe International Agency for Research on Cancer Caribbean Cancer Registry Hub (known as the Hub) was created within the framework of the Global Initiative for Cancer Registry Development, led by the International Agency for Research on Cancer and implemented by the Caribbean Public Health Agency and key partners. The Hub works closely with Caribbean PBCRs to provide training and technical support, conduct research, and promote regional cooperation. Communication between the Hub and individual PBCRs continued throughout the COVID-19 pandemic to establish its impact and to assist with developing resilient strategies to mitigate identified challenges. In 2020, the Hub supported an International Agency for Research on Cancer survey to assess the impact of the COVID-19 pandemic on PBCRs.FindingsTen (77%) of 13 Caribbean registries contacted responded to the survey. The impact of the COVID-19 pandemic on Caribbean PBCRs varied across countries. During the early phases of the pandemic, five (50%) of ten PBCRs reported that the COVID-19 pandemic negatively affected operations, mainly in terms of data collection. Reasons included inability to fully access physical data sources and reduced capacity or inability to receive cancer notifications and files. Less severe effects reported by the other five PBCRs were linked to strong existing registry infrastructure and practices, consistency of financing, and no staffing reduction. These PBCRs took independent initiatives to adapt to changes in registry operations by establishing remote access to data sources and switching from physical to virtual data abstraction when possible. A follow-up survey is underway to assess and characterise the long-term effects of the pandemic on PBCR operations, including data reporting. A crucial need identified is integrated electronic data capture systems, which can complement in-person data abstraction through increased electronic reporting from sources to PBCRs and help to strengthen registry data management systems. In response, the Hub accelerated efforts to pilot the District Health Information Software version 2 Oncology Module, developed by the Rwanda National Cancer Registry, in the Caribbean.InterpretationLessons could be learned from registries, particularly those for which operations remained largely unaffected during the pandemic. Through a better understanding of the impact of the pandemic and by improving the availability of digital solutions, the Hub is supporting efforts to strengthen the resilience of Caribbean PBCRs and health information systems in the face of emergencies.FundingFinancial support for the Hub is provided by the Caribbean Public Health Agency and the US National Cancer Institute, with in-kind support from International Agency for Research on Cancer, the North American Association of Central Cancer Registries, and the US Centers for Disease Control and Prevention. Caribbean PBCRs are funded by their respective Governments. This work received no specific funding.

The Tourism and Health Program- Safeguarding the Health and Safety of the Caribbean People and its Visitors during the COVID-19 Pandemic

The Caribbean is heavily dependent on tourism and as such, the longevity, vitality and resilience of Caribbean economies are intertwined with its travel and tourism industry. Accelerated by travel, the SARS-2-CoV virus (COVID-19), rapidly spread throughout the region concurrently crippling tourism sectors, impacting economies and threatening regional health security. The ongoing COVID-19 pandemic demonstrated the critical necessity for health in tourism. The Caribbean Public Health Agency’s Tourism and Health Program is a novel innovative program that aims to strengthen regional and national health systems and enhance the health of visitor and resident populations in addressing the health, safety, and environmental sanitation threats to tourism. This versatile program adopts a multi-faceted, multisectoral approach for implementation via surveillance and response, guidelines, capacity building, standards, policy, advocacy and partnerships, a travellers health award and mobile app. Since the advent of COVID-19, the program quickly expanded and realigned its public health tools for more rapid and relevant response to the pandemic. Implementing countries have enhanced capacity to mitigate against COVID-19 and other HSE threats to sustainable tourism. The THP is elevating Caribbean tourism by building traveller’s confidence and reinstating healthier, safer travel to the Caribbean, especially during COVID-19. This integrated program, first of its kind, continues to pioneer in setting an international precedent for improving sustainable tourism and health security

An Evaluation of Regional Cardiovascular Disease and Cancer Research Needs Using Conference Abstracts.

Background:Despite cardiovascular diseases and cancer being the leading causes of premature mortality in the Caribbean region, there is limited local research available to guide a comprehensive response to this epidemic.Objective:To evaluate cardiovascular disease and cancer research in the Caribbean using abstracts presented at the Caribbean Public Health Agency’s (CARPHA) meeting – the longest running annual research conference in the region.Method:Study data (population, intervention/exposure, comparison and outcome) were extracted from abstracts published for the 2006 to 2018 meetings. Additionally, institutional affiliation and geographic location of the first author, countries involved, sample size, study design and use of specialized testing/biomarkers were also extracted. Data were analysed using STATA version 14.Findings:A total of 1,512 abstracts, 728 posters and 784 oral presentations were reviewed. Research on cancer and cardiovascular disease comprised approximately 15% of all abstracts published annually over the review period. Most of the cardiovascular disease studies had cross sectional or survey designs (46%), with very few laboratory-based studies (<2%) and no intervention studies/clinical trials. For cancer research, 30% were cross-sectional studies/audits, 11% were case control studies, 5% were lab based and there were no clinical trials. Almost a quarter of the cardiovascular disease / cancer abstracts over the period originated from Trinidad and Tobago (26%), with Jamaica and Barbados contributing 18% and 15% respectively.Conclusion:These finding highlight the need for additional studies that can provide evidence for interventions and policy to address the region’s high cardiovascular disease and cancer burden. A Regional Centre of Research Excellence could support capacity development to facilitate this process.

COVID-19 pandemic containment in the Caribbean Region: A review of case-management and public health strategies.

COVID-19 emerged initially from Wuhan, Hubei province, China, in late December 2019, and since then, it has spread globally to be declared a pandemic by the World Health Organization. The Caribbean region started reporting COVID-19 cases in early March 2020, triggering new regional public health crises. The initial suspects and confirmed cases across the Caribbean countries were mainly imported cases and from cruise ships. The clinical manifestations varied from fever, cough, and malaise in mild cases to acute respiratory distress syndrome (ARDS) and shock in severe cases. The Caribbean Public Health Agency has provided frequent updates on the preventive strategies and quarantine measures across the Caribbean member states. COVID-19 has had a serious impact on the Caribbean region's health system, economy, and psychology. This review presents the Caribbean perspective of COVID-19, detailing the epidemiology, clinical manifestations, diagnosis, management, and preventive and surveillance measures. Vaccine hesitancy was found to be a major challenge that needs appropriate health education strategies to address the public. Strong leadership and regional collaboration among the Caribbean member states are necessary to provide optimal real-time data to the public and implement appropriate and effective guidelines in the island states.

Childhood severe acute malnutrition is associated with metabolic changes in adulthood.

BACKGROUNDSevere acute malnutrition (SAM) is a major contributor to global mortality in children under 5 years. Mortality has decreased; however, the long-term cardiometabolic consequences of SAM and its subtypes, severe wasting (SW) and edematous malnutrition (EM), are not well understood. We evaluated the metabolic profiles of adult SAM survivors using targeted metabolomic analyses.METHODSThis cohort study of 122 adult SAM survivors (SW = 69, EM = 53) and 90 age-, sex-, and BMI-matched community participants (CPs) quantified serum metabolites using direct flow injection mass spectrometry combined with reverse-phase liquid chromatography. Univariate and sparse partial least square discriminant analyses (sPLS-DAs) assessed differences in metabolic profiles and identified the most discriminative metabolites.RESULTSSeventy-seven metabolite variables were significant in distinguishing between SAM survivors (28.4 ± 8.8 years, 24.0 ± 6.1 kg/m2) and CPs (28.4 ± 8.9 years, 23.3 ± 4.4 kg/m2) (mean ± SDs) in univariate and sPLS-DA models. Compared with CPs, SAM survivors had less liver fat; higher branched-chain amino acids (BCAAs), urea cycle metabolites, and kynurenine/tryptophan (KT) ratio (P < 0.001); and lower β-hydroxybutyric acid and acylcarnitine/free carnitine ratio (P < 0.001), which were both associated with hepatic steatosis (P < 0.001). SW and EM survivors had similar metabolic profiles as did stunted and nonstunted SAM survivors.CONCLUSIONAdult SAM survivors have distinct metabolic profiles that suggest reduced β-oxidation and greater risk of type 2 diabetes (BCAAs, KT ratio, urea cycle metabolites) compared with CPs. This indicates that early childhood SAM exposure has long-term metabolic consequences that may worsen with age and require targeted clinical management.FUNDINGHealth Research Council of New Zealand, Caribbean Public Health Agency, Centre for Global Child Health at the Hospital for Sick Children. DST is an Academic Fellow and a Restracomp Fellow at the Centre for Global Child Health. GBG is a postdoctoral fellow of the Research Foundation Flanders.

Caribbean multi-centre study of Klebsiella pneumoniae: whole-genome sequencing, antimicrobial resistance and virulence factors.

The surveillance of antimicrobial-resistant isolates has proven to be one of the most valuable tools to understand the global rise of multidrug-resistant bacterial pathogens. We report the first insights into the current situation in the Caribbean, where a pilot project to monitor antimicrobial resistance (AMR) through phenotypic resistance measurements combined with whole-genome sequencing was set up in collaboration with the Caribbean Public Health Agency (CARPHA). Our first study focused on Klebsiella pneumoniae, a highly relevant organism amongst the Gram-negative opportunistic pathogens worldwide causing hospital- and community-acquired infections. Our results show that not only carbapenem resistance, but also hypervirulent strains, are circulating in patients in the Caribbean. Our current data does not allow us to infer their prevalence in the population. We argue for the urgent need to further support AMR surveillance and stewardship in this almost uncharted territory, which can make a significant impact on the reduction of antimicrobial usage. This article contains data hosted by Microreact (https://microreact.org).

Regional and global impacts of the 2007 Port-of-Spain Declaration on noncommunicable diseases.

ABSTRACTObjective.To assess how well Caribbean regional institutions (RIs) met their commitments from the 2007 Port-of-Spain Summit (POSS) declaration on noncommunicable diseases (NCDs), and evaluate the POSS impact on the United Nations High-level Meeting (HLM) on NCDs in 2011 (2011 HLM), HLM NCD review in 2014 (2014 HLM), World Health Organization’s 2025 NCD targets (2025 WHO), and 2030 Sustainable Development Goals (SDGs) agreed upon in 2015.Methods.This study uses a method developed by the University of Toronto’s Global Governance Program to measure institutions’ compliance with commitments from a summit and the match with commitments from earlier summits. This approach was supplemented using data from published literature, primary documents, and semistructured key informant interviews to detail how and why Caribbean RIs met the 2007 POSS commitments, how the 2007 POSS commitments led to compliance, and how the 2007 POSS influenced international NCD commitments.Results.Caribbean RIs implemented the 2007 POSS commitments better when they had more public legitimacy, when their missions aligned with those commitments, and when more resources were available to them. Implementation constraints arose from multiple, sometimes competing, interests of the decision-making and national implementing bodies of the Caribbean Community (CARICOM). Internationally, the early, expanding efforts of the POSS pioneers had an initially important but subsequently diminishing impact on the HLMs.Conclusions.For the Caribbean region, the Caribbean Public Health Agency should be funded to lead strengthened Caribbean RIs in coordinated action on NCDs. At the international level, the United Nations should embed NCDs in a “whole-of-global-governance” approach, monitor implementation annually, foster transregional partnerships on NCD-related themes, engage civil society, and support regular regional and global summits to enhance implementation and improvement, aimed at future HLMs on NCDs, the 2025 WHO targets, and the SDG NCD targets.

Zika virus outbreak in 19 English- and Dutch-speaking Caribbean countries and territories, 2015-2016

Background: Surveillance for zika virus was enhanced in the English- and Dutch-speaking Caribbean following emergence of zika virus in Brazil in May 2015. The first autochthonous case of zika in the Caribbean was reported by Suriname in November 2015 and since then, the virus rapidly spread throughout the region. Zika shares similar epidemiology, clinical presentation, and transmission cycle to chikungunya and dengue. However, the emergence of this new virus presented some challenges to public health professionals throughout the region. The epidemiology of laboratory-confirmed zika cases reported to the Caribbean Public Health Agency (CARPHA) for 19 English- and Dutch-speaking Caribbean countries during November 1, 2015–December 29, 2016 was documented. Methods & Materials: CARPHA Member States reported clinically suspected cases of zika and submitted serum specimens to the Agency for laboratory investigation. Real-time-polymerase-chain-reaction (RT-qPCR) was used to detect zika virus in samples taken 1 - 5 days of onset of illness. Samples taken ≥6 days of onset of illness were tested by RT-qPCR or neutralization by plaque reduction and IgM ELISA (for dengue and chikungunya virus). Due to the documented link between zika virus and congenital syndrome and zika virus and Guillain-Barré Syndrome (GBS), data on these disease outcomes were extracted and presented. Results: During the epidemic period, October 1, 2015 to December 29, 2016, 5,614 cases from 19 English- and Dutch-speaking Caribbean countries and territories were tested for arboviruses. Of these, 1,447 cases tested positive for zika virus. The majority of cases were female (83%), of which 614 (51%) were pregnant. Sixty-five percent of cases were between ages 20-44 (median 30 years, range: 5 days to 90 years). Rash, fever and arthralgia affected 87%, 63% and 60% of all reported cases, respectively. Four confirmed cases of congenital syndrome associated with zika virus infection were reported from three countries during the period. One hundred and twenty-one cases of GBS were reported from ten countries with 13 reported cases laboratory confirmed for zika virus. Conclusion: The emergence of zika virus in the English- and Dutch-speaking Caribbean underscores the threats to regional health security, the need for enhanced surveillance systems and innovative prevention and control strategies.

Tourism and Health Information System (THiS) in the Caribbean, June-September 2017

Objective: The new Tourism and Health Information System (THiS) was implemented for syndromic surveillance in visitor accommodations in the Caribbean region. The objective was to monitor for illnesses and potential outbreaks in visitor accommodations (hotels/guest houses) in the Caribbean in real-time using the web-based application.Introduction: Travel and tourism pose global health security risks via the introduction and spread of disease, as demonstrated by the H1N1 pandemic (2009), Chikungunya (2013), and recent Zika virus outbreak. In 2016, nearly 60 million persons visited the Caribbean. Historically no regional surveillance systems for illnesses in visitor populations existed. The Tourism and Health Information System (THiS), designed by the Caribbean Public Health Agency (CARPHA) from 2016-2017, is a new web-based application for syndromic surveillance in Caribbean accommodation settings, with real-time data analytics and aberration detection built in. Once an accommodation registers as part of the surveillance system, guests and staff can report their illness to front desk administration who then complete an online case questionnaire. Alternatively guests and staff from both registered and unregistered accommodations can self-report their illness using the online questionnaire in the THiS web application. Reported symptoms are applied against case definitions in real-time to generate the following syndromes: gastroenteritis, fever &amp; respiratory symptoms, fever &amp; haemorrhagic symptoms, fever &amp; neurologic symptoms, undifferentiated fever, and fever &amp; rash. Reported data is analyzed in real-time and displayed in a data analytic dashboard that is accessible to hotel/guest house management and surveillance officers at the Ministry of Health. Data analytics include syndrome trends over time, gender and age breakdown, and illness attack rates.Methods: Visitor accommodations from the following countries participated: Bahamas, Barbados, Belize, Bermuda, Guyana, Jamaica, Trinidad &amp; Tobago, and Turks &amp; Caicos Islands. National staff from the Ministry of Health, Ministry of Tourism, and/or Tourism Authority/Board engaged accommodations to participate. Participating accommodations were provided with training by national staff on how to report cases and use data analytic functions. They were asked to provide registration information to CARPHA, such as contact information to create login credentials, and data on occupancy rates for low/high seasons, number of staff, and number of lodging rooms to calculate illness attack rates. Weekly email reminders to accommodations to report cases of illness in the THiS web application, or to confirm 'nil' cases by email were sent by CARPHA staff.Results: Of the 105 accommodations engaged by national staff, 39.1% (n=41) registered to participate, accounting for 3738 lodging rooms. From epidemiological week 24-39, five cases of syndromes from three accommodations in two countries were reported in the THiS web application (Table). A case of gastroenteritis and fever &amp; respiratory symptoms were self-reported from an unregistered accommodation. Three cases of gastroenteritis were reported by hotel administration from two registered accommodations. The average response rate to weekly emails confirming 'nil' cases was 32.1% (range: 10.5-83.3%). One accommodation reported by email a cluster of 7 cases with possible conjuctivitis. No outbreaks or aberrations were detected in the THiS web application.Conclusions: Engagement of Caribbean visitor accommodations in public health surveillance is a novel but critical undertaking for promoting health, safety, and security for both visitors and locals in the tourism dependent Caribbean region, but it will take time to establish. Confirming the absence of illness is an important public health endeavor for visitor accommodations. Preliminary results have demonstrated that it is possible for public health to work in a voluntary basis with the private accommodation sector. To establish more consistent and reliable reporting public health legislation and policies will need to be explored. As more data is gathered, assessments of the validity and sensitivity of the system will need to be conducted.

Developing policy to support novel Caribbean Tourism and Health surveillance program

ObjectiveThe Regional Tourism and Health program (THP) is a novel program, comprising of a tourism surveillance system, training, standards and multisectoral partnerships. The objective was to develop regional mandate and policy to support this new program and its non-traditional surveillance system.IntroductionIn January 2016, the Caribbean Public Health Agency (CARPHA), serving 24 Member States(MS), began executing a regional Tourism and Health program (THP), recognizing that the health of Caribbean economies is closely related to the health of its tourism industry since the Caribbean is most tourism-dependent region in the world; that tourism is vulnerable to health, safety and environmental (HSE) threats; and that travel and tourism impacted on global health security. High and increasing visitors to the Caribbean can increase the health, safety and security risks by the introduction and spread of diseases, by both residents and visitors. This was exemplified by the H1N1 pandemic (2009), Chikungunya (2013), and the recent Zika epidemic. However, even though more people visit the Caribbean than reside, there is no regional visitor/tourism surveillance system. There is also no regional mandate and policy for the reporting of visitor/tourism illnesses. This coupled with inadequate training, lack of standards and collaboration between tourism health stakeholders have contributed to disease spread.The THP is an innovative, multifaceted, integrated, regional program with components of a web based real time Tourism and Health Information Surveillance and Response system (THiS), food safety and environmental sanitation training, standards and multisectoral health and tourism partnerships. It aims to promote the health, safety and security of Caribbean visitors and residents. The THP is novel in that it involves the implementation of a non- traditional, health information and surveillance system (visitor based illnesses), new data users (private sector, hotels, passenger ships, visitors), new partners (tourism sector) and at regional level. Given the novelty and the multisectoral nature of the THP, a critical factor to support its implementation and sustainability was the development of regional mandate and policy to facilitate real time surveillance and response to detect and reduce the spread of illness.MethodsA multiprong approach was used to develop regional mandate and policy for the unique multisectoral THP program, from January 2016 to October 2017. This consisted of (i) weekly advocacy meetings with national and regional tourism and health public and private stakeholders to gain buy-in, recognition and support (ii) requesting letters of commitment from MS (iii) seeking support from the Caribbean Chief Medical Officers of Health (CMOs), who advises the Ministers of Health, at their annual meeting and convening a special CMO meeting on the THP (iv) seeking Ministers of Tourism support through the Caribbean Tourism Organization(CTO) forum (v) inclusion of tourism and health as a priority in the Caribbean Cooperation in Health (CCH4) strategy (which sets health priorities for the Caribbean region) (vi) presenting the THP to the Council for Human and Social Development (COHSOD), consisting of Caribbean Ministers of Health requesting approval to develop a regional THP policy (September 2017) and (viii) convening of a regional THP stakeholders meeting (October 2017) with high level decision makers from national, regional and international health and tourism sectors.ResultsA multiprong approach was used to develop regional mandate and policy for the unique multisectoral THP program, from January 2016 to October 2017. This consisted of (i) weekly advocacy meetings with national and regional tourism and health public and private stakeholders to gain buy-in, recognition and support (ii) requesting letters of commitment from MS (iii) seeking support from the Caribbean Chief Medical Officers of Health (CMOs), who advises the Ministers of Health, at their annual meeting and convening a special CMO meeting on the THP (iv) seeking Ministers of Tourism support through the Caribbean Tourism Organization(CTO) forum (v) inclusion of tourism and health as a priority in the Caribbean Cooperation in Health (CCH4) strategy (which sets health priorities for the Caribbean region) (vi) presenting the THP to the Council for Human and Social Development (COHSOD), consisting of Caribbean Ministers of Health requesting approval to develop a regional THP policy (September 2017) and (viii) convening of a regional THP stakeholders meeting (October 2017) with high level decision makers from national, regional and international health and tourism sectors.ConcludsionsDeveloping regional mandate and policy is a complex and long, but critical necessity for the implementation and the sustainability of this novel, multisectoral, non-traditional, multi-country tourism and health surveillance and response program. While the regional policy will take time to finalize, CARPHA and MS now have regional mandate to support the implementation of the THP, to strengthen capacity to prepare for, mitigate and respond to public health threats, which can transcend national boundaries.

Zika virus outbreak in 19 English- and Dutch-speaking Caribbean countries and territories, 2015-2016.

ABSTRACTSurveillance for Zika virus was enhanced in the English- and Dutch-speaking Caribbean following emergence of the virus in Brazil in May 2015. The first autochthonous case of Zika in the Caribbean was reported by Suriname in November 2015, and the virus subsequently spread rapidly throughout the region. Caribbean Public Health Agency (CARPHA) member states (CMS) reported clinically suspected cases of Zika and submitted serum specimens to the agency for laboratory investigation. A patient was considered a confirmed case if Zika virus was detected by real-time reverse transcription–polymerase chain reaction (RT-PCR) assay or serological test. Due to the documented link between 1) Zika virus and congenital syndrome, and 2) Zika virus and Guillain–Barré syndrome (GBS), data on both of these disease outcomes were extracted from country and regional reports. This special report describes the epidemiology of laboratory-confirmed Zika cases reported to CARPHA, including links with both congenital syndrome and GBS, for 19 English- and Dutch-speaking Caribbean countries during the epidemic period (1 October 2015–29 December 2016).

Prolonged Zika virus viremia in a patient with Guillain-Barré syndrome in Trinidad and Tobago

ABSTRACTAn emerging mosquito-borne flavivirus, Zika virus (ZIKV) is a significant public health concern because of the syndromes associated with the infection. In addition, ZIKV is considered a major problem due to large-scale spread of the disease and the possible clinical complications for the central nervous system, especially Guillain-Barré syndrome (GBS) and microcephaly. Since the introduction of ZIKV in the Caribbean, molecular detection of the viral RNA has been utilized as a more specific and sensitive approach to demonstrating acute infection. However, it is generally accepted that the virus has a short viremic period, generally less than 5 days. Serologic testing has the inconvenience of strong cross-reactivity among flaviviruses, such as dengue and yellow fever. As part of the laboratory surveillance activities for Zika and other arboviruses at the Caribbean Public Health Agency, in 2016 a sample from a male who was clinically diagnosed with GBS tested positive for Zika virus by real-time polymerase chain reaction (rRT-PCR). The serum sample had been taken on day 21 after the onset of symptoms. The case had initially been characterized as a typical ZIKV infection (mild fever with a generalized maculopapular rash). Later, weakness of limbs and other peripheral neurological symptoms appeared. Enzyme-linked immunoassay (ELISA) showed that the sample was negative for IgM antibodies against Zika, Chikungunya, and dengue viruses. The plaque reduction neutralization test was positive for ZIKV. This indicated parallel development of viremia and immune response against ZIKV. Recent reports have demonstrated a longer duration of the viremia in ZIKV infections. However, our report is the first one that links the infection with extended viremia and the development in parallel of a GBS case.

A Novel Hotel-based Syndromic Surveillance System for the Caribbean Region

ObjectiveTo describe the Caribbean Public Health Agency’s (CARPHA)Tourism and Health Information System (THiS), a web-basedsyndromic surveillance system to increase the capacity of Caribbeancountries to monitor the health of visitors and staff in hotels, anddetect potential infectious disease outbreaks for early and coordinatedpublic health response.IntroductionThe tourism industry is highly vulnerable to Health, Safety, andEnvironmental Sanitation (HSE) threats. The Caribbean is the mosttourism dependent region in the world, with over 54.2 million stay-over and cruise ship arrivals in 2015, generating revenues of $US29.6billion and contributing to 15% of the Gross Domestic Product (GDP)and 2,255,000 jobs [1]. Tourists and staff are at an increased risk ofacquiring infectious diseases, given the mass-gathering of individualswith varying levels of susceptibility and often times in close quartersin hotels and cruise ships. To prevent the spread of infectious diseasesin these settings, early warning and response to potential publichealth threats is essential. To increase the capacity of countries in theCaribbean monitor and protect the health of tourists and staff in theirhotel establishments, THiS was designed as an early warning systemfor infectious disease outbreaks.MethodsCARPHA launched the Regional Tourism Health Information,Monitoring and Response System in 2016 with donor fundingreceived from the Inter-American Development Bank (IDB). Theoverall objective of THMRS project from 2016-2018 is to improveparticipating country’s capacity to provide cost-effective and qualityhealth, food safety and environmental solutions to HSE threats.As part of the THMRS project, the development of a hotel-basedsyndromic surveillance system for early warning and response toinfectious diseases was developed.THiS was developed in collaboration with six participating IDBcountries: Barbados, Bahamas, Belize, Guyana, Jamaica, Trinidadand Tobago. The implementation plan (2016-2018) with each countryinvolved three stages:1) Project Operations, Coordination, Management (includingAdvocacy, and Endorsement)2) Development of the project outputs: gap analysis and bestpractices; development of surveillance guidelines and trainingmodules, HSE Standards3) Implementation in participating countries (i.e. technical visits,ongoing technical coordination): Preparation, Buy-in, Training andLaunchThe web-based design of THiS enables the collection of real-time data which will inform health service delivery decisions/policies, strengthen national and regional health monitoring efforts,and trigger a rapid coordinated response to outbreaks, and preventescalation of tourism HSE incidents. The system involves a web-based questionnaire with a series of 11 short questions that ask theuser for basic non-identifiable demographic information as well assymptoms. The reported symptoms are used by the system to generatesix syndromes: Gastroenteritis, Undifferentiated Fever, HemorrhagicFever, Fever with Neurologic symptoms. Fever with Respiratorysymptoms, Fever with Rash.Data entry persons include hotel staff, physicians, and the case.Access to anlaytic dashboards of the aggregated data is limited toregistered hotel staff (i.e. Managers), the Ministry of Health of thecountry where the hotel reporting is located, and CARPHA.The limited level of baseline data for syndromes in the Caribbeanregion means that statistical aberration detection mechanisms formost syndromes will not be available until THiS collects at least oneyear’s worth of data. However, for acute gastroenteritis, until a moreaccurate threshold can be generated, a cut-off of 3% ill (staff andguests) will be used for alerting potential outbreaks. This is scheduledto be live and functional beginning in hotel facilities in Trinidad andTobago at the beginning of October 2016.By the end of 2016, THiS will be operating in facilities in all sixparticipating countries, allowing for the collection of baseline data forsyndromes occurring among tourists and staff in hotel-settings, andproviding a mechanism to detect and response to emerging publichealth threats early and efficiently.ConclusionsEstablishing this system is critical to improving countries’capacities to support the overall health surveillance system of thetourism-dependent Caribbean economies, enabling countries tocollect real-time data which will inform health service deliverydecisions/policies, strengthen national and regional health monitoringefforts to trigger a rapid coordinated response to outbreaks and othercrises and thus prevent tourism HSE incidents.

Development and implementation of the Caribbean Laboratory Quality Management Systems Stepwise Improvement Process (LQMS-SIP) Towards Accreditation.

BackgroundImplementing quality management systems and accrediting laboratories in the Caribbean has been a challenge.ObjectivesWe report the development of a stepwise process for quality systems improvement in the Caribbean Region.MethodsThe Caribbean Laboratory Stakeholders met under a joint Pan American Health Organization/US Centers for Disease Control and Prevention initiative and developed a user-friendly framework called ‘Laboratory Quality Management System – Stepwise Improvement Process (LQMS-SIP) Towards Accreditation’ to support countries in strengthening laboratory services through a stepwise approach toward fulfilling the ISO 15189: 2012 requirements.ResultsThis approach consists of a three-tiered framework. Tier 1 represents the minimum requirements corresponding to the mandatory criteria for obtaining a licence from the Ministry of Health of the participating country. The next two tiers are quality improvement milestones that are achieved through the implementation of specific quality management system requirements. Laboratories that meet the requirements of the three tiers will be encouraged to apply for accreditation. The Caribbean Regional Organisation for Standards and Quality hosts the LQMS-SIP Secretariat and will work with countries, including the Ministry of Health and stakeholders, including laboratory staff, to coordinate and implement LQMS-SIP activities. The Caribbean Public Health Agency will coordinate and advocate for the LQMS-SIP implementation.ConclusionThis article presents the Caribbean LQMS-SIP framework and describes how it will be implemented among various countries in the region to achieve quality improvement.

English

Objective: To determine the status of existing violence and injury prevention (VIP) efforts and surveillance systems in the Caribbean. Methods: The Caribbean Public Health Agency (CARPHA) undertook a survey to gather evidence of VIP in 24 CARPHA member states. The survey was administered to national epidemiologists and non-communicable disease focal points in October 2015 using an online tool, ‘Survey Monkey’. Questions were asked about the availability in each country of VIP representative surveys, policies, action plans, laws, victim support services, and surveillance systems. Results: Nineteen (79%) countries completed the VIP survey. Only three (16%) countries indicated having conducted a nationally representative survey. Twelve (63%) had not developed a national policy, and 14 (74%) had not implemented an action plan on VIP. Each country reported the existence of VIP laws and offered victim support services, though average law enforcement ranged from 40% to 79%. Nine (47%) countries indicated using an injury registry, and 15 (79%) reported collecting injury data using in-patient records, mainly from public hospitals. All 19 countries confirmed that records of reported violent incidents were maintained by the police. Unique identifiers were generally lacking in registries and data collected by the police. Only four (44%) countries with registries, 10 (67%) countries with in-patient injury data, and 12 (63%) countries with police records indicated that the data were shared with other organizations. Conclusion: Each country reported some level of injury surveillance system. However, such systems should be harmonized to produce more complete baseline data. The use of unique identifiers is required to reduce duplication and effectively link surveillance systems available in countries.

Politics of Ebola and the critical role of global health diplomacy for the CARICOM.

The 2014 Ebola epidemic was the largest in history, affecting Guinea, Liberia, Sierra Leone, Nigeria, and Mali in West Africa. The International Health Regulations are legally binding in 194 countries including all the member states of WHO “to prevent, protect against, control, and provide a public health response to the international spread of disease.” Since the Caribbean Community region heavily depends on tourism, a single case of the disease anywhere in the region could have serious negative consequences for the rest of the region's tourism industry. Global health diplomacy brings together the disciplines of public health, international affairs, management, law, and economics and focuses on negotiations that shape and manage the global policy environment for health. The regional institutes such as Caribbean Public Health Agency should play a more proactive and pivotal role in the creation of regional response teams in all the island nations collaborating with the departments of public health and epidemiology at the regional campuses of The University of the West Indies. The role of global health diplomacy and its practice should be encouraged to reach a consensus among the stakeholders considering the threat to the health security in the region. There is a need for the cadre of global health diplomats who has a critical understanding of health and also the practice of diplomacy since such serious health issues have implications at the global level in this globalized world.

First reported enterovirus D68 infection in pediatric patients from the Caribbean region: evidence of spread from the U.S. outbreak

ABSTRACTThe 2014 enterovirus D68 (EV-D68) outbreak in the United States raised concerns about the introduction of the virus in the Caribbean region. The objective of this study was to provide rapid evidence of the introduction of EV-D68 strains in the Caribbean region during the 2014 outbreak in the United States, using a relatively simple phylogenetic approach. From October 2014 to May 2015, four EV-D68 cases from two countries (Bermuda and Dominica) were detected at the regional referral laboratory at the Caribbean Public Health Agency (Port of Spain, Trinidad and Tobago) based on molecular testing of respiratory specimens. All cases were children presenting to hospitals with moderate respiratory distress. No cases of acute flaccid paralysis were detected. Phylogenetic analysis of the Caribbean strains showed more than 99% similarity with the 2014 U.S.-outbreak strain, providing evidence of the introduction and circulation of the virus in the region.