An epidemiological description of illness in passengers and crew at the Bridgetown Barbados port and cruise terminal

OBJECTIVE: To describe and analyse the epidemiology of illnesses experienced by passengers and crew arriving at the Bridgetown Port, Barbados between 2009 and 2013. DESIGN AND METHODS: Data were extracted from the passenger and crew arrival registers and passenger and crew illness logs. This was done for all vessels arriving at the Bridgetown Port between January 2009 and December 2013. Data were entered into an Epi Info database and analysis done using Epi Info Version 7. RESULTS: There were 1031 cases of illness from over 3 million passenger visits and 1 million crew. The overall event rate for communicable illnesses was 15.7 (95% CI 14.4 - 17.1) per 100,000 passengers, and for crew was 24.0 (21.6 - 26.6) per 100, 000 crew. Gastroenteritis was the predominant illness experienced by passengers and crew followed by influenza. The event rate for gastroenteritis among passengers was 13.7 (12.5 -15.0) per 100,000 and 14.4 (12.6, 16.5) for crew. The event rate for non-communicable illnesses was 3.4 per 100,000 passengers with myocardial infarction being the main diagnosis. The event rate for non-communicable illnesses among crew was 2.1 per 100,000, the leading cause being injuries. CONCLUSIONS: The predominant illnesses reported were gastroenteritis and influenza similar to previous published reports from around the world, but gastroenteritis was the predominant illness, unlike most other published studies. There is a role for Port Health Officers to assist the food safety and sanitation efforts on cruise liners and more frequent inspections and investigations of diseases outbreaks may be helpful.

Economic and health burden of rotavirus gastroenteritis for the 2003 birth cohort in eight Latin American and Caribbean countries

OBJECTIVES: To estimate the health and economic burden of rotavirus gastroenteritis in hospital and outpatient settings in eight Latin American and Caribbean countries (Argentina, Brazil, Chile, Dominican Republic, Honduras, Mexico, Panama, and Venezuela). METHODS: An economic model was constructed using epidemiological data from published articles, national health administration studies, and country-specific cost estimates. For each of the eight countries, the model estimated the rotavirus outcomes for the 2003 birth cohort during the first five years of life. The main outcome measures included health care costs, transporation cost, lost wages, and disease burden expressed in disability-adjusted life years. Estimates were discounted at a rate of 3 percent. Sensitivity analyses evaluated the impact of specific variables on the medical cost of treating rotavirus. RESULTS: For every 1000 children born during 2003 in the eight Latin American and Caribbean countries studied here, we estimated that rotavirus gastroenteritis would result in an average of 246 outpatient visits, 24 hospitalizations, 0.6 deaths, and US$7971 in direct medical costs during their first five years of life. The incidence of rotavirus-associated outpatient visits and the cost of outpatient visits were predicted to have the largest impact on the total medical cost per child. CONCLUSIONS: Rotavirus gastroenteritis is likely to result in substantial disease and economic burden to health systems in Latin America and Caribbean countries, and the foreseeable burden to health systems in Latin America and Caribbean countries, and the foreseeable burden should be important an consideration in evaluating the cost-effectiveness of vaccination (AU)

A randomized clinical trial comparing oral ondansetron with placebo in children with vomiting from acute gastroenteritis

STUDY OBJECTIVE: Vomiting in children suffering from acute gastroenteritis interferes with the oral rehydration process and equally frustrates parents and health care providers. Adjuncts such as promethazine and metoclopramide are less than optimally effective and are associated with side effects. Ondansetron, a 5-HT3 receptor antagonist marketed as Zofran, is a safe and effective antiemetic used extensively in oncology and postoperative patients. We evaluate the effect of the antiemetic ondansetron versus placebo on the clinical outcome of patients with vomiting from gastroenteritis in a pediatric emergency department. METHODS: This was a randomized, prospective, double-blind clinical trial in a university-affiliated children's hospital ED. Children between the ages of 6 months and 12 years who had vomited at least 5 times during the preceding 24 hours were randomized to receive either oral ondansetron or a taste- and color-matched placebo. Oral rehydration was commenced 15 minutes later at 5 mL/min per standard oral rehydration protocols. Patients were discharged after they voided and continued standard oral rehydration at home with the introduction of a bananas, rice, applesauce, and toast (BRAT) diet after the first 24 hours. Any patient requiring admission was considered a treatment failure, and no further doses were given. Discharged patients were given 5 additional doses to be used every 8 hours, and they were contacted by telephone 24 and 48 hours after discharge to record the number of episodes of vomiting and diarrhea. The parents were also required to complete a diary of the same information, which was mailed to the investigators for confirmation of the telephone data. RESULTS: One hundred forty-five patients were enrolled, of whom 51% (n=74) were randomized to ondansetron. At baseline, age distribution, sex, and severity of illness did not differ between the ondansetron and placebo groups. During the observation period in the ED, the median number of episodes of vomiting was 0 in both groups, but the rank sum of vomiting episodes was significantly lower in the ondansetron group (P =.001). The number of episodes of emesis in the ED after enrollment ranged from 0 to 7 in the placebo group and 0 to 2 in the ondansetron group. During the 48 hours of follow-up, the median number of episodes of vomiting remained 0, with no statistically significant difference between the groups. There was no statistically significant difference in the rank sum of episodes of diarrhea in the ED between the groups (P =.622); however, during the next 48 hours, the patients in the ondansetron group had significantly more diarrhea than the placebo group. A lower proportion of patients receiving ondansetron compared with placebo required intravenous fluid therapy (P =.015). The admission rate was also lower in patients receiving ondansetron (P =.007). The revisit rate was higher in the ondansetron group compared with the placebo group (P =.047).CONCLUSION: Ondansetron was effective in reducing the emesis from gastroenteritis during the ED phase of oral rehydration and in lowering the rates of intravenous fluid administration and hospital admission.

Nitric oxide levels in children with febrile illnesses - Poster abstract

OBJECTIVE: To determine nitric oxide (NO) levels in children with febrile illness and to investigate its prognostic value in early dengue virus infections. DESIGN AND METHOD: A pilot case control study was conducted from September 1998 to March 1999 at the Eric Williams Medical Sciences Complex, Priority Care Facility (PCF), in Trinidad. Serum NO concentrations were measured in children <12 years presenting with febrile illnesses in the absence of clinically significant bacterial infection. RESULTS: Of 59 blood samples collected, there were 22 from individuals diagnoses as virally induced gastroenteritis (VGE), with 31 non-specific viral illnesses (VI), and 6 viral infections associated with upper-respiratory tract infection (URTI-VI). The mean (NO) in all cases was above normal (11.9 uM SD 5.9) 81.17 uM in VGE, 41.30 uM in VI and 57.83 uM in URTI-VI. Krushkal-Wallis test revealed that there was a significant difference (p = 0.007) between all three means and that the mean (NO) for VGE was significantly higher (p = 0.003) than that of VI. CONCLUSIONS: The degree of elevation of NO varies between viral illnesses in children and its potential as a rapid prognostic marker warrants further investigation.(AU)

Gastro-enteritis in Dominica: from major cause of morbidity and mortality to minor primary care condition

Gastro-enteritis continues to be a major health problem in the developing world, especially in children. We studied morbidity and mortality rates of gastro-enteritis in the past 50 years in Dominica. All cases of gastro-enteritis registered during one year at the different levels of the primary health care services in the Marigot Health district were analysed. In a total district population of 8,554, 296 cases of gastro-enteritis (incidence 3,460/100,000) presented to the Casualty Department of the Marigot District Hospital and the district health centres. Of these, 143 were referred to the District Medical Officer. A total of 44 cases were admitted to the Marigot district hospital for short term observation and oral rehydration therapy. Only one child needed to be referred to the secondary level of care at the Princess Margaret Hospital. From being a major cause of morbidity and mortality, as well as a major reason for admission to hospital wards in the past 50 years, gastro-enteritis has become a minor condition which is generally treated at primary levels of health care. In addition to increased affluence and socio-economic conditions, this enormous improvement is attributed to the introduction of oral rehydration therapy and the development of easily accessible primary health care services.(AU)

A scoring system for use in the diagnosis of acute abdominal pain in childhood

A statistical analysis was undertaken of 1158 children admitted to a surgical ward for the management of acute abdominal pain. Over two-thirds (40 percent) of the children had non-specific abdominal pain while 29.7 percent had appendicitis. The remainder were found to have had urinary tract infections (11.7 percent), constipation (7.5 percent), gastroenteritis (5.8 percent) or intussusception (5.3 percent). A stepwise discriminant analysis of the data collected during their evaluation was performed, using the BMDP statistical software package. Demographic and clinical features, as well as the results of ancillary investigations, were included in the data. The programme generated a classification function of a sub-set of 18 variables which best discriminated among the diagnostic groups. The coefficients of the classification functions were then combined with the rank order of selection of the variables to derive a scoring method for predicting the diagnosis. The results of urine culture were excluded since these would be unavailable during early clinical assessment. The scores for the diagnostic groups fell within the following ranges: - 1 - 23 non-specific abdominal pain; 20 - 48 appendicitis; 35 - 84 gastroenteritis; 75 - 88 constipation and 89 - 140 intussusception. It is suggested that this scoring method be evaluated by a prospective study to test its validity (AU)

Salmonellosis in the Barbadian population

Salmonellosis is increasing worldwide and is affecting millions of people. Because the effects of gastroenteritis caused by Salmonella species are usually mild, there is a great deal of under-reporting. Barbados needs to monitor salmonellosis carefully for the sake of its own population and for the preservation of its reputation as a "tourist haven". In this country over the period 1980-1983 259 isolates of Salmonella spp. were obtained from 7,031 specimens sent to the National laboratories (incidence rate 3.7 percent; crude morbidity rate 1.0/1000 population). The 1990-93 period showed a significant increase in the rate of Salmonella isolates when compared to 1980. Salmonella spp. were isolated from 468 of 9,372 specimens sent to the laboratory (incidence rate 5 percent; crude morbidity rate 1.8/1000 population; p<0.0001). Gastroenteritis in children has always been a concern of the Barbados Ministry of Health, and this study shows that 59.8 percent (1980-83) and 50.9 percent (1990-93) of the cases reported were children under five years old. Salmonellosis was found throughout the island, but the largest concentration of cases was reported from the city parish where the population density was highest (50 percent in 1980 and 48 percent in 1993). The crude morbidity rate in this parish was 47.4/1000 compared to the smallest rate of 0.4/1000 in St. Joseph. Four major outbreaks were identified over the 1990-93 period affecting tourists and nationals and claiming two lives. Eggs were incriminated as the source of the organism in two of the outbreaks even though laboratory confirmation was not possible. Salmonella typhimurium was the causative factor in two of the major outbreaks and was the most prominent serotype isolated (18 percent) was responsible for the majority of cases hospitalized (51.5 percent). The increasing number of cases of salmonellosis in the Barbadian population has not been linked directly to poultry and egg contamination. However, data from the Veterinary Laboratory has shown that chickens are the animals from which Salmonella spp. is most often recovered and the serotypes identified are similar to those identified from human cases of salmonellosis. The situation warrants further research and implementation of stricter public health control measures. (AU)

Breast feeding in developing countries

Human milk has recently been reappraised with respect to its nutritional content, and anti-infective properties. Concerns with global food supply, economics of infant feeding, contraception and prevention of infections are specially relevant to developing countries. The benefits of breast feeding for the Third World is highlighted, reviewing the special advantages over adapted cow's milk (AU)

Viral gastroenteritis

Gastroenteritis, a common, self limiting disease, is characterised by a spectrum of clinical symptoms which may include nausea, vomiting, diarrhoea, dehydration, abdominal pain, malaise and fever in varying combinations. It occurs in both epidemic and endemic forms and although rarely fatal in developed countries, is a leading cause of nortality in children in underdeveloped countries (AU)

The Kingston Project. III. the effects of high energy supplement and metronidazole on malnourished children rehabilitated in the community: morbidity and growth

In the Kingston Project malnourished children referred from public health clinics to a metabolic ward were treated at home using community health aides within the existing health service. We have previously provided anthropometric results showing significantly greater gains in weight and length for groups given a high energy supplement (3.31 MJ daily) for 3 months during treatment, and greatest gains for a group treated with metronidazole at the beginning of supplementation [Heikens et al., Eur. J. Clin. Nutr. 43, 145-160 (1989); 47, 160-173 (1993)]. We now present findings on morbidity and relate these to the separate interventions and to growth velocities. Although referral was solely on nutritional criteria, 65 percent of the sample were found to have additional illnesses at enrolment. During the study period (6 months) upper respiratory tract infections (URTI) were the commonest illness in all groups; there were significantly more gastroenteric infections in the group given the supplement, but not the antibiotic treatment; the children who received only the standard health service care were ill more often and for longer periods than children in the other groups. Diarrhoea, fever and dysentery prevalences were all found to relate significantly to weight velocity, and although prevalences differed between treatment groups, the detrimental effect on velocity was similar whichever the group (AU)

Case fatality-rate of severely malnourished children 0 - 48 months admitted to three medical institutions in Jamaica

Malnutrition in early childhood remains a common cause of admission and mortality in Jamaica. This study aims at determining trends in case-fatality rates of severely malnourished children 0 - 48 months admitted in three medical institutions in Jamaica from 1982 to 1991. The institutions are the paediatric wards of University Hospital of the West Indies (UHWI), Tropical Metabolism Research Unit (TMRU) and Bustamante Hospital for Children (BHC). Assessment of these children were based on the routine physical examination conducted by the physician. There was a docket search for random subsamples which showed discrepencies in certain categories of malnutrition at UHWI and BHC. There was a total of 3,268 malnourished children in the sample. Children in the age rang 0 - 1 year accounted for 60.2 percent of the admission. Kwashiorkor totalled 806 (24.7 percent) and maramus 507 (15.7 percent), marasmic-kwashiorkir 299 (9.1 percent) and other nutritional deficiencies 1656 (50.7 percent) of the admissions. The peak years of admission of malnourished children to hospitals were 1983 - 1986. Of the deaths, 198 (77.9 percent) occurs in children under 1 of age. Fifty (19.7 percent) of the deaths were in children between the ages 1 - 2 years and 6 (2.4 percent) were in the age range 2 - 4 years. Annual case-fatality rates ranged from 0 - 20 percent. There were no discernible trend in the case fatality rates within the three institutions. UHWI had a case-fatality rate ranging from 0 - 9.4 percent, TMRU 0 - 14.4 percent and BHC 3.0 - 20.0 percent . TMRU admitted and nursed more children in the severe category of malnutrition, but recorded the second highest case-fatality rate. BHC admitted more malnourished children, but less in the severe category and recorded the highest case-fatality rate. Gastro-enteritis, respiratory infections and septicemia were the three most common conditions associated with death of children. Gastro-enteritis occured in one-third of the admissions (34.5 percent). Multiple regression analysis showed that 74 percent of the annual variation in numbers of protein energy malnutrition deaths at B. H. C. was accounted for by (a) number of admissions, (b) percentage change in consumer price index and (c) percentage change in the US$ value of the Jamaican $, together, leaving a maximum of 26 percent for the realm of variations in hospital care. Findings suggest a minor role for export in-patient management in reducing deaths from protien energy malnutrition (AU)

An outbreak of rotaviral gastroenteritis in Belize - abstract

An outbreak of gastroenteritis was identified in Belize in February 1991. Forty-five of the 467 cases reported through mid-March were tested for the presence of rotavirus antigen in faecal specimens, using an ELISA method. Of these, 23 (51 percent) were positive. An analysis of 1,605 cases of gastroenteritis reported since October, 1988 at a clinic in Belize City, indicated that the outbreak was seasonal, with an increase in incidence January through May and a peak incidence January through March. The seasonally coincides with the rainfall pattern in Belize. This supports the supposition that the mode of transmission for rotavirus is faecal-oral. There was no significant difference in the sexual distribution. Over 69 percent of the reported cases in the outbreak and approximately 45 percent of the historical cases were in infants and children less than 4 years of age. The percentage of cases in individuals more than 4 years of age is higher than would be expected in an outbreak due solely to rotavirus and suggesting other aetiologies were responsible for some cases (AU)

The benefits and limitations of sentinel surveillance data on gastroenteritis in epidemic investigation

Sentinel surveillance playes an important role in the early detection of disease outbreaks. In Jamaica, information is collected weekly on gastroenteritis (GE), fever, and measles. Recently, GE data has been divided into cases in under 5 year olds and over 5 year olds in order to increase the system's sensitivity towards detection of the introduction of cholera. Investigation of a recent epidemic of gastroenteritis at Cornwall Regional Hospital, Montego Bay, St. James Parish reinforced to us the importance of sentinel data collection for detection of outbreaks and illustrated the usefullness of age division of GE data, but also alerted us to the need to monitor the accuracy of case definitions for sentinel reports (AU)

Epidemiology and transmission of rotavirus infections and diarrhoea in St. Lucia, West Indies

To determine the epidemiology and risk factors of rotavirus in St. Lucia, 229 children in three valleys with varying levels of sanitation were studied for 2 years. A four-fold rise in complement fixation antibody to rotavirus antigen was used in paired samples as evidence of recent infection. Results showed that forty-eight per cent of infants experienced at least one infection during a two-year period, and 17 percent of children were reinfected. Infections occured within the first months of life and peaked between 6 and 23 months of age. The peak infection coincided with the dry season in each age group. Children breast-feeding had fewer infections. Although crowding within the home was significantly associated with repeated infection, the incidence of infection was not affected by the degree of sanitation. Other studies in the region, using recently developed techniques, concur with these findings which advance our understanding of the epidemiological importance of rotavirus in St. Lucia. Although these studies provide insights into the risk factors for rotavirus infections, other studies are required to determine whether investments should be focused on improved sanitation or immunization or both (AU)

Post-disaster epidemiological surveillance following Hurricane Hugo in Montserrat - abstract

Hurricane Hugo struck the island of Montserrat during the night of 17th September, 1989. Sustained winds of 130 mph were experienced for 8 hours with damage to 93 per cent of buildings; 50 per cent seriously and 20 per cent destroyed. The main hospital lost its roof and most health centres were severely affected. Two thousand five hundred persons were rendered homeless, of whom 1,000 were housed in shelters. Three days after, environmental health surveillance revealed unsatisfactory conditions in shelters with inadequate water supplies and faecal disposal. Water was trucked to shelters and a pit latrine programme commenced so that by the first week of October, all shelters had acceptable faecal disposal facilities. Island-wide, symptom-based daily reports of disease surveillance was introduced 9 days after the hurricane for respiratory infections and gastroenteritis. This allowed daily monitoring of disease occurrence by locality, targeting of health education and environmental health measures, and made it easier to dispel rumors which occurred after the hurricane. There was an increase in gastroenteritis 10 - 14 days after, but this subsided as potable water supplies were established. One month after, 30 cases of fever of unknown origin were detected. At first suspected to be dengue fever, it turned out to be influenza A (hl, N1) (AU)

Nosocomial and community acquired infections in malnourished Jamaican children - abstract

Infection is a contributing or initiating factor in children with inadequate food intake who develop malnutrition, and malnutrition by virtue of immunosuppression leads to further episodes of infection. In this prospective study, 206 community acquired and 73 nosocomial infections occurring in 50 hospitalised severely malnourished children were investigated. This represented an average of 5.6 episodes of infection per child. Predominant community acquired infections in the 50 children included gastroenteritis (68 percent), otitis media (60 percent), rhinopharyngitis (60 percent), oral candidiasis (46 percent), skin infections (40 percent), pneumonia (28 percent), bacteraemia (24 percent), and bacteriuria (18 percent). The most frequent nosocomial infections were rhinopharyngitis (34 percent), lower respiratory tract infections (24 percent) and septicaemia (18 percent). In those infections where an aetiological agent was identified, Giardia lamblia was the commonest enteric pathogen and Klebsiella sp. were recovered from the majority of urines. Coagulase Negative Staphylococcus was the most frequent aetiological agent of bacteraemia, 12 of the 13 episodes were associated with fever +/- leucocytosis and in six episodes this organism was recovered from two or more blood culture sets. The lack of clinical signs and symptoms, and the atypical presentation in some of the infected malnourished children were attributed to impairment of the acute inflammatory response. Nasal, throat and axillary swabs taken on admission revealed significant colonisation with coliforms and pneumococcus; however, these swabs were not useful as indicators of potentially infective organisms. Two of the four deaths were attributed to infection. The role of Cryptosporidium, an enteric pathogen which is prevalent in immunocompromised hosts, was further investigated. Cryptosporidium was isolated from the stools of 19.5 percent (15/77) malnourished children compared to 2.4 percent (10/436) well-nourished children, who were more likely to present with fever, vomiting, prolonged diarrhoea and dehydration. Community acquired non-bacterial respiratory tract infections were further investigated from paired sera in 83 moderately malnourished children. In 60 percent of the children with a history of respiratory tract disease and 25 percent of those without reported disease, a specific non-bacterial infection was diagnosed. Multiple aetiological agents were identified in 6 of the 42 chidren with respiratory disease. The most common micro-organisms observed were: Para-influenza 1,2 or 3 (in 15 children), Influenza H1N1, H2N3 or "B" in 12, Adenovirus in 10, Respiratory Syncitial Virus in 7 and Mycoplasma Pneumoniae in 6 children. These three studies report a high prevalence of common and unusual infections, especially Cryptosporidium enteritis and Coagulase Negative Staphylococcus bacteraemia, occurring in these immunocompromised children. Diagnosis of infection requires a high index of suspicion and a comprehensive screening system (AU)

Childhood gastroenteritis in Barbados: occurrence of Campylobacter and Rotavirus

Four hundred children with diarrhoea whose ages ranged from 3 months to 6 years were investigated to determine the aetiology of childhood gastroenteritis in Barbados. Rotavirus (11 percent) was the most frequently identified pathogen, followed by Shigella (7 percent), enteropathogenic E. coli (4 percent), Salmonella (3 percent) and C. jejuni (1.3 percent) with 2 percent of patients having multiple pathogens. No pathogens were identified in the remaining cases studied. The ages of the patients with C. jejuni enteritis ranged from between 4 months and 2 years (mean 1.3 years). The male/female ratio was 2:1. The most frequent symptoms were fever (66 percent) and bloody diarrhoea (66 percent). The duration of stool excretion ranged from between 1 and 7 weeks. The organisms were uniformly sensitive to antibiotic tests against erythromycin, tetracycline, chloramphenicol, gentamicin and nitrofurantoin. In contrast, the ages of patients with rotavirus enteritis ranged between 3 months and 4 years (mean 1.3 years) with a male/female ratio of 1:1, and the most frequent symptoms were diarrhoea (80 percent), vomiting (70 percent) and upper respiratory infections. In 60 percent of patients, hospitalisation was necessary. All patients had an uneventful recovery (AU)

The quality of care is related to death rates: hospital inpatient management of infants with acute gastroenteritis in Jamaica

The quality of care of random samples of about 40 infants admitted with acute gastroenteritis to each of five hospitals in Jamaica was assessed. Low levels of adherence to consensus care criteria appeared to be correlated with high levels of hospital-specific severity standardized mortality ratios X100 (SSMRs): poor adherence, SSMR 127-230; intermediate adherence, SSMR 95 ; good adherence, SSMR 14. The main deficiencies in care at certain hospitals were: non-weighing of infants, incomplete physical examination, inadequate estimation of fluid requirements, and irregular recording of fluid intake. To improve the effective care of infants with gastroenteritis, a quality assurance program is required (AU)