Re-emergence of tuberculosis in the Caribbean: how ready are the Caribbean laboratories in 1997?

The incidence of tuberculosis is increasing in the English speaking Caribbean and multiple drug resistant M. tuberculosis has been reported. Twenty-one laboratories in the Caribbean were surveyed to assess their current practices and capabilities for the detection, isolation and drug susceptibility testing of M. tuberculosis. Sixteen laboratories perform laboratory diagnosis of tuberculosis, most commonly by the Kinyoun technique (10/16). Microscopic examination of sputum for acid fast bacilli (AFB) was being performed in 12 laboratories by the direct method. Only one laboratory used fluorochrome methods for the rapid detection of AFB in sputum and other clinical specimens. Only five laboratories culture for mycobacteria. None of the laboratories perform either nucleic acid probes of BACTEC NAP for the identification of mycobacteria other than tuberculosis (MOTT). Only three laboratories performed antimicrobial susceptibility testing in the Caribbean. Centrifuges with safety carriers were being used in only 13 percent of laboratories. Eight laboratories (50 percent) used level 2 containment biological safety cabinets while processing all specimens for mycobacterial infections. Reporting of smear results to hospital, physician or the ministry of health/public health department was mainly done by telephone. The time taken to report AFB smear microscopy results averaged over 48 hrs in 75 percent of laboratories. Implementation of CDC recommendations and laboratory quality standards for the control of tuberculosis are urgently needed in the Caribbean.(AU)

External quality assessment of cervical vaginal cytology laboratory screening in the Caribbean - abstract

A model external quality assessment of cervical/vaginal cytology laboratory screening (PAP Smear) programme was piloted during 1996 to assess the proficiency of cytopathologists and cytotechnologists and to provide an opportunity for review/and reassessment of results as an integral component of continuous quality improvement of cytology services in the Caribbean. Eight pathologists and 22 cytotechnologists/technicians from seven Caribbean laboratories participated in this survey which consisted or reviewing eight reference slides provided by the Laboratory Proficiency Testing Program (LPTP, Ontario). The overall agreement with the LPTP results ranged from 5 percent to 63 percent in cytotechnologists as compared to cytopathologists (13 percent to 73 percent). The percentage agreement for severe dysplasia was between 22 percent (cytotechnologists) and 25 percent (cytopathologists), while better rates were observed for invasive carcinoma (60 - 63 percent). Inflammatory effects ere missed by both cytotechnologists (73 percent) and cytopathologists (49 percent). Moderate dysplasia was missed by both categories of laboratory professionals. There was a wide inter-laboratory variation of results as compared eith the LPTp (0 to 100 percent). Generally, laboratory professionals have placed greater emphasis on cervical biopsy, repeat smear, and provided guarded reports on PAP smears. The data show that there is a wide variation in the interpretation and reporting of cervico-vaginal cytology smears in Caribbean laboratories. Hence, there is an urgent need for continuous quality assessment and improvement of cervical cancer cytology screening services in the Caribbean (AU).

Neonatal varicella in Jamaica: a report of two cases

Two cases of neonatal varicella in Jamaica are reported. This condition is reported for the first time in the Caribbean. Though the condition is rare, it is important to be aware of life-saving measures to be adopted in severe neonatal varicella.(AU)

Influenza A virus associated neurological disorders in Jamaica

During 1979, three cases of influenza A virus infection associated with neurological disorders were observed. In all three cases the virus was isolated from the cerebrospinal fluid. A mechanism for the development of post-influenzal encephalopathy is postulated (AU)

Influenza virus infections in Jamaica between 1977 and 1985

Data on influenza virus infections between 1977 and 1985 in Jamaica are presented. The occurrence of influenza varied each year. The peak incidence correlated generally with the peak occurrence of acute respiratory illness each year. The influenza-associated neurological (17 percent) and cardiac (9.7 percent) manifestations were seen during the period of study. Antigenic variants of influenza viruses circulating in Jamaica were similar to those recorded world-wide. Continuous virological and non-virological surveillance are vital in determining the impact of influenza on associated mortality and morbidity in a developing country like Jamaica. (AU)

Toxoplasmosis in young Jamaicans

Of 511 young (1-19 years of age) Jamaicans sampled for IgG antibodies to Toxoplasma by the ELISA method, there was an overall prevalence of 45 percent. Seropositivity ranged from 24-26 percent in the 2-year-olds, up to 54 percent in the 5-9-year-olds. There was no significant difference in prevalence between the sexes, but there was a statistically significant difference between the rates from rural uplands (58 percent), urban uplands (46 percent), rural lowlands (40 percent), and urban lowlands (32 percent).(Summary)

High burden of antimicrobial resistance in Neisseria gonorrhoeae in the Caribbean, 1994-96: implication for the National STD Prevention and Control Programme

Gonorrhoea remains an important source of morbidity in the Caribbean. Despite decreasing rates of gonococcal infection, the proportion of isolates which are resistant to antimicrobials has increased dramatically in developing and developed countries. The objective of this study was to obtain reliable data on trends in antimicrobial susceptibility patterns and to identify new resistant strains through the surveillance network for gonococcal antimicrobial resistance patterns in the Caribbean. The prevalence rate of penicillinase producing N. gonorrhoeae (PPNG) ranged between 4 percent and 64 percent in isolates from 1994 to 1996 in 12 countries surveyed. High rates of PPNG were recorded in Suriname (70 percent), Guyana (77 percent), Bahamas (62 percent) and Barbados (57 percent). St Lucia was the only country not reporting the presence of PPNG. High levels of tetracycline resistant N. gonorrhoeae (TRNG) were present in four countries. Fifty-seven percent of N. gonorrhoeae isolates in Guyana were TRNG. The MIC50 and 90 to ciprofloxacin and ceftriaxone were 2-4 times higher in PPNG isolates than MICs for susceptible strains in three countries. The total burden of antibiotic resistance (penicillin and tetracycline) ranged from 42.5 to 92.9 percent in three countries. This study clearly demonstrates the need for monitoring of antimicrobial susceptibility pattern of N. gonorrhoeae for successful implementation of national guidelines for the treatment of genital discharge syndrome.(AU)

Clinical aspects of pyogenic liver abscess: the University Hospital of the West Indies experience

Twenty-four cases of pyogenic liver abscess admitted between 1977 and 1986 are presented. A mean age of 43 years (range 5-78) with a 3:1 male:female ratio and 25 percent mortality were noted. Fever and abdominal pain were encountered in over 80 percent of cases and anorexia and malaise in over 60 percent. Hepatomegaly and right upper quadrant tenderness were the commonest signs. Leucocytosis, raised alkaline phosphatase and y-glutamyl transpeptidase, and hypoalbuminaemia were each noted in roughly 80 percent of cases. None of these showed any prognostic significance. Predisposing factors were noted in 11 cases. No cases of associated biliary disease were noted. Multiple polymicrobial, aerobic and mixed aerobic/anaerobic abscesses were associated with a high mortality. Patients aged over 50 years or more also had a higher mortality (P<0.05). Anaerobic abscesses were often solitary and were associated with a lower mortality (P<0.05). Surgical drainage and guided precutaneous drainage showed no difference in morbidity. (AU)

Infectious mononucleosis in the University of the West Indies

The clinical features and laboratory parameters in sixteen confirmed cases of Infectious Mononucleosis (IM) seen at the University Hospital of the West Indies between 1975 and 1989 were reviewed. The common presenting features were lymphadenopathy (14/16), fever (13/16) and pharyngitis (7/16). Atypical lymphocytosis was present in 10 cases and heterophile antibodies (HA) in 9 cases. The aetiology and laboratory diagnosis of IM are briefly discussed. (AU)

Knowledge and understanding of AIDS among health-care workers in Jamaica

Six hundred and fifty questionnaires were sent to Health-care Workers (HCW) in four hospitals to assess the knowledge and understanding on HIV transmission and isolation precautions to be instituted for control and also to ascertain whether any differences in knowledge existed between HCW of teaching and non-teaching hospitals. Five hundred and nine questionaires were returned, a response rate of 79 percent . Questions on HIV transmission via blood transfusion and sexual intercourse and proper disposal of sharp instruments received the highest scores (85-100), embracing all groups of teaching and non-teaching hospitals. The greatest area of misconception and misunderstanding was reflected in responses obtained on isolation precautions (<30) for both teaching and non-teaching hospitals. Our study emphasizes an urgent need for comprehensive, continuous education of HCW on prevention and control of HIV infections in Jamaica (AU)

Ecology of vibrio cholerae and vibrio parahaemolyticus in Trinidad's coastal waters - abstract

An ecological survey of Vibrio cholerae and Vibrio parahaemolyticus in the coastal waters of Trinidad was conducted between October, 1992 and March, 1993 to examine what factors may contribute to the presence, persistence and possibility of disease transmission to the susceptible human population of Trinidad. One hundred and thirty-two samples (water, plankton and shell fish) were investigated by standard microbiological procedures for the isolation and identification of Vibirio spp. in the marine environment. Water samples from the north coast did not yield any Vibrio species. None of the water, food or plankton samples from the 2 east coast stations were positive for V.cholerae or V.parahaemolyticus though other pathogenic halophilic Vibrio species were isolated. The Gulf Coast stations showed the presence of both V.cholerae and V.parahaemolyticus in differing percentages. V.parahaemolyticus was present at the Caroni Swamp, Williams Bay, Cedros Bay and Othaheite Bay in varying percentages according to type of sample. V.cholerae was not isolated at Caroni Swamp but was present at Williams Bay (a popular bathing spot), Cedros Bay (oysters and plankton) and Othaheite Bay. Planktonic copepods were seen to be a reservoir for both species. The study demonstrates that the waters of the Gulf of Paria satisfy ecological requirements for the growth, persistence and disease transmission of Vibrio spp. to the susceptible population of Trinidad. Water from the South American mainland that is contaminated with V.cholerae may enter and circulate within the Gulf for up to 6 days and this may be an important factor in the occurrence and persistence of these pathogenic bacteria in Trinidadian waters (AU)

The general public's perceptions and use of antimicrobials in Trinidad and Tobago

Objective: To determine the general public's perception and use of antibiotics in Trinidad and Tobago, a two-island republic in the Caribbean. Methods. This prospective study surveyed 824 randomly selected households listed in the telephone directory, from November 1998 to January 1999. Through telephone interviews we determined knowledge about antibiotics and beliefs concerning their safety and efficacy. We studied the influence of age, gender, education, and having private health insurance on knowledge, self-medication, storing medication at home for emergency use ("hoarding"), and asking a private doctor to prescribe antibiotics ("demand prescribing"). Results. For the 824 telephone calls that the interviewers completed, 753 of the households agreed to participate (91.4 percent response rate). Of those 753 participants, 699 of them (93 percent) knew the term "antibiotic", 29 percent (206/699) said it was a drug for bacterial infections, and 25 percent (170/690) had asked a doctor for an antibiotic prescription. Penicillin was correctly identified as an antibiotic across age, gender, and education categories, but 36 percent of respondents incorrectly said Benadryl (diphenhydramine), a common over-the-counter cough and cold formulation, was an antibiotic. Gender was not significantly associated with knowledge of antibiotic safety, with self-medication, or with hoarding antibiotics. On the other hand, completion of tertiary (university) education was significantly associated with correct knowledge of the safety of antibiotics and whether they could cure all infections. Of the various antimicrobials, beta-lactams were the ones that survey respondents had used most frequently in the preceding year, and 20 percent of antibiotics users had used multiple antibiotics in that period. In comparison to persons with private health insurance, more individuals without private health insurance said that antibiotics are safe and do not have side effects, and more of them also incorrectly called aspirin and Benadryl antibiotics. Conclusions. In Trinidad and Tobago, inappropriate use of antimicrobials results from self-medication, over-the-counter availability at the community pharmacy, prescribing on demand, and lack of regulatory control. In order to contain antibiotic abuse, both the Drug Inspectorate of the Ministry of Health and the Pharmacy Board should exert stricter control on the dispensing of antibiotics at private pharmacies. Further, education of the general public and of health care professionals on antibiotic misuse and appropriate use must be instituted, along with community-based surveillance of antimicrobial resistance trends (AU)

Bacteriological study of diabetic foot ulcers

Bacteriological study of 61 patients with diabetic gangrene of non-gangrenous foot ulcers was undertaken to determine the pattern of infection and antimicrobial susceptibility with a view to suggest optimal antibiotic therapy for these patients. Grangrenous ulcers showed a higher frequency of mixed infection: the predominant organisms being enterococci, Proteus sp., Pseudomonas sp. and Klebsiella sp. Infected nongrangrenous ulcers showed Staph. pyogenes, and beta haemolytis Streptococcus as single organism in 12 patients. Anaerobes were more frequent isolated in gangrenous lesions than in non-gangrenous ulcers. Antimicrobial susceptibility showed that gram positive organisms were sensitive to co-trimoxazole, cephaloridine, ampicillin and penicillin. Gram negative aerobic bacilli were sensitive to gentomycin, chloramphenicol, cotrimoxazole and streptomycin. Anaerobes were sensitive to chloramphenicol, clindamycin and metronidazole. Antibiotics of choice for gangrenous lesions with spreading infection and septicaemia are a combination of gentamycin, ampicillin and metronidazole as an adjuvant to surgical treatment. (AU)

Prediction of post-operative wound infection by a simple score system

Eight hundred and twenty-nine surgical patients were monitored for post-operative wound infections as well as associated risk factors from January to December 1980 at the University Hospital of the West Indies. Age over 50 years,diabetes mellitus, duration of pre-operative hospitalisation, urgency of operation, duration of operation > 2 hours and the degree of wound contamination were found to be association with increased risk of infection. A simple score system has devised to predict the overall risk of infection. A simple score system has been devised to predict the overall risk of wound infection in general surgical patients (AU)

Infectious meningitis at the University Hospital of the West Indies. Review of clinical and laboratory findings (1965-1980)

A retrospective study is reported on 215 cases of infectious meningitis seen during a 16-year period (1965-1980) at the University Hospital of the West Indies, Kingston, Jamaica. A detailed analysis was made of the aetiology, epidemiology, signs and symptoms, associated conditions, laboratory investigations, treatment regimes as well as outcome. The most common causative organism of bacterial meningitis was Streptococcus pneumoniae (29.3 percent), being seen in all age groups except in neonates. Haemophilus influenzae (23 percent) was the most frequent cause in pre-school children. Unusual pathogens constituted a major group of bacterial meningitis, accounting for 34 (21.3 percent). Of 11 neonates recorded, 7 (63.6 percent) belonged to this latter group. There were 48 (22.3 percent) cases of aseptic meningitis, 5 tuberculous and 2 cryptococcal. The overall mortality was 14.4 percent. The fatality rate in pneumococcal meningitis was 25.5 percent whereas in that caused by Haemophilus it was 2.7 percent. No deaths were recorded in the aseptic group. The gram stain was useful in 65 percent of cases of bacterial meningitis. One third of aseptic cases had 50 percent or more of neutrophils in the CSF. The highest CSF white cell count in aseptic and bacterial meningitis was 2,176 and 36,000 cells/mm3, respectively. The highest CSF protein level in bacterial and aseptic meningitis was 774 mg/100 ml and 150 mg/ml, respectively. Because of the high incidence of unusual pathogens, there is a need for a modified approach to initial antibiotic treatment bearing in mind the multiple antibiotic-resistant strains that are frequently encountered (AU)

Infection in a multidisciplinary intensive care unit at the University Hospital of the West Indies

The records of 1,252 patients were reviewed to determine the incidence of infection, mortality and associated risk factors in our multi-disciplinary intensive care unit (MD-ICU) during the period 1977 to 1982. The infection rate and the mortality rate were 24 percent and 22 percent respectively. The mortality rate in the infected group was 25 percent. The infection rate was higher in the intra-abdominal and trauma group as compared to the cardio-thoracic group (P<0.05). The incidence of ICU-acquired respiratory tract infection (41 percent), wound infection (17 percent) and urinary tract infection (15 percent) was significantly different from non-ICU acquired infections (P<0.05). The commonest site of infection was the respiratory tract (37 percent). The incidence of infection was directly related to the duration of medical devices left in situ and the length of stay in the unit (more than seven days) (AU)

Thyroid function in dengue fever, meningitis, encephalitis, poliomyelitis and other febrile conditions

Thyroid function was studied by estimating serum thyroxine (T4), triodothyronine (T3) and thyrotropin (TSH) in 52 patients suffering from dengue fever, bacterial meningitis, viral encephalitis, paralytic poliomyelitis and other febrile illnesses. Mean serum concentrations of total T4 and T3 were significantly lower in all patients except those suffering from poliomyelitis. Serum TSH was significantly low in dengue fever and pyrexia of unknown origin (PUO). Though the TSH levels were also low in patients with bacterial meningitis and encephalitis, the differences were not statistically significant. Decreases in serum T4, T3 and FT1 in severe illnesses as compared to normal subjects may signify a state of secondary hypothyroidism of a functional type. It will be erroneous to say that decreases in T4 and T3 in systemic illnesses is entirely an adaptive or protective process to maintain metabolic rate. The possible value of thyroid hormone replacement therapy in these illnesses needs further investigations. (AU)

Antimicrobial resistance seen as an emergent problem by physicians in Trinidad - Poster abstract

OBJECTIVE: To understand the influences of antibiotic prescription practices of physicians in Trinidad on emergent bacterial resistance. DESIGN AND METHOD: A pre-tested questionnaire was self-administered to physicians to determine the factors influencing the choices and outcomes of antimicrobial prescribing. RESULTS: 56 physicians with a mean of 7.1 years experience participated in the survey. The most frequent prescriptions were for urogenital infections (50 percent), respiratory tract infections (48.2 percent) and skin and soft tissue infections (46.4 percent). Amoxil was the drug of choice for respiratory infections (42.1 percent), Flagyl and Septra (17.9 percent) each for genitourinary (GU) infections and doxycycline (41.4 percent) for STD's. Only 8.9 percent of physicians prescribed antibiotics for the common cold/flu. Patient's well-being was the priority in prescribing followed by emergent bacterial resistance. Approximately 76.7 percent of participants observed resistance in the community, especially to Amoxil (26.1 percent). Overprescribing (61.7 percent) was viewed as a major contributor to resistance. Physicians would like to depend on the laboratory to curtail resistance and want more educational programmes. CONCLUSIONS: This study identified the recognition of bacterial resistance as a physician concern and a need to study antibiotic use.(AU)

Antimicrobial resistance in the Caribbean - Poster abstract

OBJECTIVE: To determine the resistance patterns of organisms causing hospital and community acquired infections in the English-and Dutch-speaking Caribbean. METHOD: The data on antimicrobial resistance of gram negative bacteria isolated in six laboratories during the first 6 month period in 1998 and pathogens isolated from community infections in selectedcountries during 1994-1997 were reviewed. RESULTS: The overall resistance of gram negative aerobic bacilli (excluding salmonella spp and shigella spp)to ampicillin (range 51-85 percent), gentamicin (range 3-11 percent and trimethoprim-sulphamethoxazole (range 27 to 47 percent) did not significantly differ between the laboratories and countries. The resistance to third generation cephalosporins was 9 percent and 16 percent in two laboratories in Trinidad. Multiple antibiotic resistant S typhimurium PT 104b, S heidelberg, Sh flexnerii type 2/2a and low levels of ampicillin and gentamycin resistant S enteritidis strains causing community acquired enteric infections were observed in the Caribbean. The rates of penicillin resistant pneumococci (1 percent) and chloramphenicol resistant H. influenzae ( 3 percent) were low in the Caribbean. CONCLUSIONS: The potential for introduction and spread pf resistance genes in the Caribbean is very high. Hence, continuing surveillance of antimicrobial resistant pathogens in nosocomial and community is essential in the Caribbean. (AU)

Use of disinfectants and antiseptics in Jamaican health care institutions - a knowledge, attitudes, beliefs and practices study - abstract

Little has been published concerning choices and use of disinfectants and antiseptics in Caribbean health care institutions. This paper reports some findings from a cross-sectional study of knowledge, attitudes, beliefs and patterns of use concerning those chemicals. The study was carried out among 176 distributors or users from 12 public health care institutions in the cities and major rural towns of Jamaica. Most respondents acknowledged no distinction between the terms "disinfectant" and "antiseptic". Pharmacies gave the most accurate definitions. Fifteen per cent of all respondents failed to give any definition. In general, female respondents were better informed than males. Bleach, "Savlon" (R) and phenolics were the most commonly used disinfectants, while alcohol was seldom acknowledged for this purpose. Disinfectants were supplied sometimes as concentrates and sometimes in diluted form; they were not always stored appropriately and were often over- or under-diluted. Few respondents knew the recommended strengths for effective disinfection and chemosterilization. Concerning disinfectants, a small number of ancillary workers and registered nurses listed "smell" as their most important characteristic. Some persons believed that all disinfectants are safe and effective for all purposes. When supplies were short, inappropriate substitution occurred in 37 percent of cases. Policy guidelines for cleaning and disinfection are urgently needed in Jamaican health institutions. Education of health workers should stress appropriate selection, storage, and monitoring of the use of disinfectants and antiseptics. Pre-employment and in-service training of workers in infection control, including disinfectant use, is highly recommended (AU)