Human papillomavirus genotype distribution in cervical samples among vaccine naïve Barbados women.

PURPOSE: This study was undertaken to provide baseline HPV genotype distribution among women in Barbados before HPV immunization was introduced. This information would then be used as a denominator for post-vaccine surveillance and is expected to aid in understanding the effect of vaccination on cervical disease in Barbados. METHODS: Liquid-based cytology specimens were collected from 413 women (age range 18-65 years) attending three clinics, in a pre-vaccination, population-based study. After consent was obtained, sexual behavior and socio-demographic information were acquired from self-administered questionnaires. HPV types were detected using Luminex-based HPV PCR genotyping methodology. RESULTS: HPV was detected in 33% (135/413) of the subjects overall (95% CI 32.7, 33.37), of which 70% (95/135) were high-risk types, with 35 different types being detected in this population. Single and multiple high-risk HPV types were detected in 14% (13/95) and 31% (29/95) of the subjects, respectively. The most common high-risk HPV types detected were 45(n = 22, 23%), 16 (n = 17, 18%), 52 (n = 16, 17%), and 58 (n = 10, 11%). Persons with the highest level of infection by age were 21-25 (n = 25/135;19%; 95% CI 18.8, 19.3); 26-30 (n = 22/135;16%; 95% CI 15.9, 16.2); 31-35 (n = 19/135;14%; 95% CI 13.9, 14.2); 36-40 (n = 17/135;13%; 95% CI 12.2, 13.2), and 18-21 (n = 15/135;11%; 95% CI 10.9, 11.2). 91/413 (22%) persons had a normal cytology result. CONCLUSION: A high prevalence of HPV type 45 was found in the screening population of women in Barbados. The results of cytological examinations and HPV positivity suggest that both tests should be used for greater reliable diagnosis of HPV infection.

First clinical reports of acute hantavirus and dengue infections among pregnant women in the Caribbean.

BACKGROUND: Hantavirus and dengue virus infections lead to diseases causing economic and public health concerns. Acute hantavirus infections can lead to similar clinical haemorrhagic signs as other endemic diseases including dengue and leptospirosis. METHODS: Using a retrospective case analysis of pregnant dengue and hantavirus disease patients with clinical reports and compatible clinical laboratory information during pregnancy, we report the first evidence of dengue and hantavirus infections and a case of dual dengue and hantavirus infection among pregnant women in the Caribbean. Laboratory testing by enzyme-linked immunosorbent assay (ELISA) and non-structural protein 1 (NS1) for DENV and for hantavirus infection pseudotype focus reduction neutralisation tests (pFRNT), ELISA and immunochromatographic (ICG) strips. RESULTS: Four pregnant cases with acute DENV infections were identified; however, only one out of the four cases (25%) had a detailed medical record to permit abstraction of clinical data. Six hantavirus infected pregnant cases were identified with gestation periods ranged from 36 to 39 weeks; none of the reported patients exhibited previous pregnancy complications prior to hospitalisation and infection. Acute liver damage was observed in three of the six cases (AST readings) who were subsequently diagnosed with hepatitis in pregnancy and variable clinical outcomes were observed with term and pre-term deliveries. CONCLUSIONS: Whilst hantavirus infection in pregnancy is rare, consideration should be given to differential diagnosis with fever, kidney involvement, liver involvement, haemorrhagic symptoms and thrombocytopenia in endemic areas with clinically similar diseases such as dengue and leptospirosis.HighlightsFirst recorded case of hantavirus and dengue co-infection in a pregnant woman.First detailed report of clinical hantavirus infection in pregnant women in the Caribbean.First published report of clinical dengue infection in pregnant woman in the Caribbean.Possible complications of pregnancy following hantavirus infection.Pre-term birth and low birth weights.Clinical course of hantavirus infection in a Caribbean population.

Student Satisfaction and Self-Efficacy in a Novel Online Clinical Clerkship Curriculum Delivered During the COVID-19 Pandemic.

Purpose: The COVID-19 pandemic has caused significant disruption to medical education and clinical training and resulted in stressors that impede student learning. This study aimed to assess student satisfaction and self-efficacy in a novel online clinical clerkship curriculum delivered during the COVID-19 pandemic. Methods: Fourth- and fifth-year medical students completed an online survey in January 2021 covering the following areas: student satisfaction, self-efficacy, and perceived effectiveness of online versus face-to-face learning. Results: Just over half of students (51%) were satisfied with online clerkship delivery. However, fewer than half of students (46%) believed online learning effectively increased their knowledge, compared to 56% of students who believed face-to-face learning was effective. The perception of the effectiveness of online learning and face-to-face teaching for clinical skills was 18% and 89%, respectively (p < 0.0001). Few students perceived online teaching to be effective for developing social competencies (27%) compared to face-to-face instruction (67%) (p < 0.001). In addition, mean self-efficacy scores were higher for persons who perceived online teaching to be effective for increasing knowledge, improving clinical skills, and developing social competencies. Overall, students' perception of online learning was strongly associated with online self-efficacy. Conclusion: Student satisfaction and perceived self-efficacy in online learning were higher than reported acceptance of online clerkship curriculum.

Serological Evidence of Multiple Zoonotic Viral Infections among Wild Rodents in Barbados.

BACKGROUND: Rodents are reservoirs for several zoonotic pathogens that can cause human infectious diseases, including orthohantaviruses, mammarenaviruses and orthopoxviruses. Evidence exists for these viruses circulating among rodents and causing human infections in the Americas, but much less evidence exists for their presence in wild rodents in the Caribbean. METHODS: Here, we conducted serological and molecular investigations of wild rodents in Barbados to determine the prevalence of orthohantavirus, mammarenavirus and orthopoxvirus infections, and the possible role of these rodent species as reservoirs of zoonotic pathogens. Using immunofluorescent assays (IFA), rodent sera were screened for the presence of antibodies to orthohantavirus, mammarenavirus (Lymphocytic choriomeningitis virus-LCMV) and orthopoxvirus (Cowpox virus-CPXV) infections. RT-PCR was then conducted on orthohantavirus and mammarenavirus-seropositive rodent sera and tissues, to detect the presence of viral RNA. RESULTS: We identified antibodies against orthohantavirus, mammarenavirus, and orthopoxvirus among wild mice and rats (3.8%, 2.5% and 7.5% seropositivity rates respectively) in Barbados. No orthohantavirus or mammarenavirus viral RNA was detected from seropositive rodent sera or tissues using RT-PCR. CONCLUSIONS: Key findings of this study are the first serological evidence of orthohantavirus infections in Mus musculus and the first serological evidence of mammarenavirus and orthopoxvirus infections in Rattus norvegicus and M. musculus in the English-speaking Caribbean. Rodents may present a potential zoonotic and biosecurity risk for transmission of three human pathogens, namely orthohantaviruses, mammarenaviruses and orthopoxviruses in Barbados.

Serological Evidence of Human Orthohantavirus Infections in Barbados, 2008 to 2016.

BACKGROUND: Hantavirus pulmonary syndrome (HPS) is well-known in South and North America; however, not enough data exist for the Caribbean. The first report of clinical orthohantavirus infection was obtained in Barbados, but no other evidence of clinical orthohantavirus infections among adults in the Caribbean has been documented. METHODS: Using enzyme linked immunosorbent assay (ELISA) tests followed by confirmatory testing with immunofluorescent assays (IFA), immunochromatographic (ICG) tests, and pseudotype focus reduction neutralization tests (pFRNT), we retrospectively and prospectively detected orthohantavirus-specific antibodies among patients with febrile illness in Barbados. RESULTS: The orthohantavirus prevalence rate varied from 5.8 to 102.6 cases per 100,000 persons among febrile patients who sought medical attention annually between 2008 and 2016. Two major orthohantavirus epidemics occurred in Barbados during 2010 and 2016. Peak orthohantavis infections were observed observed during the rainy season (August) and prevalence rates were significantly higher in females than males and in patients from urban parishes than rural parishes. CONCLUSIONS: Orthohantavirus infections are still occurring in Barbados and in some patients along with multiple pathogen infections (CHIKV, ZIKV, DENV and Leptospira). Orthohantavirus infections are more prevalent during periods of high rainfall (rainy season) with peak transmission in August; females are more likely to be infected than males and infections are more likely among patients from urban rather than rural parishes in Barbados.

Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health.

Antimicrobial resistance (AMR) is a serious threat to global public health. It increases morbidity and mortality, and is associated with high economic costs due to its health care burden. Infections with multidrug-resistant (MDR) bacteria also have substantial implications on clinical and economic outcomes. Moreover, increased indiscriminate use of antibiotics during the COVID-19 pandemic will heighten bacterial resistance and ultimately lead to more deaths. This review highlights AMR's scale and consequences, the importance, and implications of an antimicrobial stewardship program (ASP) to fight resistance and protect global health. Antimicrobial stewardship (AMS), an organizational or system-wide health-care strategy, is designed to promote, improve, monitor, and evaluate the rational use of antimicrobials to preserve their future effectiveness, along with the promotion and protection of public health. ASP has been very successful in promoting antimicrobials' appropriate use by implementing evidence-based interventions. The "One Health" approach, a holistic and multisectoral approach, is also needed to address AMR's rising threat. AMS practices, principles, and interventions are critical steps towards containing and mitigating AMR. Evidence-based policies must guide the "One Health" approach, vaccination protocols, health professionals' education, and the public's awareness about AMR.

Highly Sensitive Virome Characterization of Aedes aegypti and Culex pipiens Complex from Central Europe and the Caribbean Reveals Potential for Interspecies Viral Transmission.

Mosquitoes are the most important vectors for arthropod-borne viral diseases. Mixed viral infections of mosquitoes allow genetic recombination or reassortment of diverse viruses, turning mosquitoes into potential virologic mixing bowls. In this study, we field-collected mosquitoes of different species (Aedes aegypti and Culex pipiens complex), from different geographic locations and environments (central Europe and the Caribbean) for highly sensitive next-generation sequencing-based virome characterization. We found a rich virus community associated with a great diversity of host species. Among those, we detected a large diversity of novel virus sequences that we could predominately assign to circular Rep-encoding single-stranded (CRESS) DNA viruses, including the full-length genome of a yet undescribed Gemykrogvirus species. Moreover, we report for the first time the detection of a potentially zoonotic CRESS-DNA virus (Cyclovirus VN) in mosquito vectors. This study expands the knowledge on virus diversity in medically important mosquito vectors, especially for CRESS-DNA viruses that have previously been shown to easily recombine and jump the species barrier.

Spatiotemporal Tools for Emerging and Endemic Disease Hotspots in Small Areas: An Analysis of Dengue and Chikungunya in Barbados, 2013-2016.

Dengue fever and other febrile mosquito-borne diseases place considerable health and economic burdens on small island nations in the Caribbean. Here, we used two methods of cluster detection to find potential hotspots of transmission of dengue and chikungunya in Barbados, and to assess the impact of input surveillance data and methodology on observed patterns of risk. Using Moran's I and spatial scan statistics, we analyzed the geospatial and temporal distribution of disease cases and rates across Barbados for dengue fever in 2013-2016, and a chikungunya outbreak in 2014. During years with high numbers of dengue cases, hotspots for cases were found with Moran's I in the south and central regions in 2013 and 2016, respectively. Using smoothed disease rates, clustering was detected in all years for dengue. Hotspots suggesting higher rates were not detected via spatial scan statistics, but coldspots suggesting lower than expected rates of disease activity were found in southwestern Barbados during high case years of dengue. No significant spatiotemporal structure was found in cases during the chikungunya outbreak. Spatial analysis of surveillance data is useful in identifying outbreak hotspots, potentially complementing existing early warning systems. We caution that these methods should be used in a manner appropriate to available data and reflecting explicit public health goals-managing for overall case numbers or targeting anomalous rates for further investigation.

Serum LPS Associated with Hantavirus and Dengue Disease Severity in Barbados.

Hantavirus and dengue virus (DENV) infections are caused by RNA viruses which infect immune systems' cells including monocytes, macrophages and dendritic cells and occur year-round in Barbados. A retrospective serological study (2008-2015) was conducted on hantavirus and dengue patient sera confirmed by IgM and IgG ELISA, NS1 and RT-PCR using Limulus amoebocyte lysate (LAL) kinetic turbidimetric method to determine serum endotoxin levels. Hantavirus patients were categorized into two groups, namely (a) hospitalized and (b) non-hospitalized. Dengue patients were categorized into 3 groups using 2009 WHO dengue guidelines (a) severe dengue (SD), (b) hospitalized non-severe dengue (non-SD) and (c) non-hospitalized non-SD. Statistical analyses were conducted to determine the association of endotoxin levels with hantavirus disease severity based on hospitalization and dengue disease severity. Serum endotoxin levels are associated with hantavirus disease severity and hospitalization and dengue disease severity (p < 0.01). Similar studies have found an association of serum endotoxin levels with dengue disease severity but never with hantavirus infection. Co-detection of hantavirus- and DENV-specific IgM in some patients were observed with elevated serum endotoxin levels. In addition, previous studies observed hantavirus replication in the gut of patients, gastrointestinal tract as a possible entry route of infection and evidence of microbial translocation and its impact on hantavirus disease severity. A significant correlation of serum endotoxin and hantavirus disease severity and hospitalization in hantavirus infected patients is reported for the first time ever. In addition, serum endotoxin levels correlated with dengue disease severity. This study adds further support to the role of endotoxin in both hantavirus and dengue virus infection and disease severity and its role as a possible therapeutic target for viral haemorrhagic fevers (VHFs).

Co-developing climate services for public health: Stakeholder needs and perceptions for the prevention and control of Aedes-transmitted diseases in the Caribbean.

BACKGROUND: Small island developing states (SIDS) in the Caribbean region are challenged with managing the health outcomes of a changing climate. Health and climate sectors have partnered to co-develop climate services to improve the management of emerging arboviral diseases such as dengue fever, for example, through the development of climate-driven early warning systems. The objective of this study was to identify health and climate stakeholder perceptions and needs in the Caribbean, with respect to the development of climate services for arboviruses. METHODS: Stakeholders included public decision makers and practitioners from the climate and health sectors at the regional (Caribbean) level and from the countries of Dominica and Barbados. From April to June 2017, we conducted interviews (n = 41), surveys (n = 32), and national workshops with stakeholders. Survey responses were tabulated, and audio recordings were transcribed and analyzed using qualitative coding to identify responses by research topic, country/region, and sector. RESULTS: Health practitioners indicated that their jurisdiction is currently experiencing an increased risk of arboviral diseases associated with climate variability, and most anticipated that this risk will increase in the future. National health sectors reported financial limitations and a lack of technical expertise in geographic information systems (GIS), statistics, and modeling, which constrained their ability to implement climate services for arboviruses. National climate sectors were constrained by a lack of personnel. Stakeholders highlighted the need to strengthen partnerships with the private sector, academia, and civil society. They identified a gap in local research on climate-arbovirus linkages, which constrained the ability of the health sector to make informed decisions. Strategies to strengthen the climate-health partnership included a top-down approach by engaging senior leadership, multi-lateral collaboration agreements, national committees on climate and health, and shared spaces of dialogue. Mechanisms for mainstreaming climate services for health operations to control arboviruses included climatic-health bulletins and an online GIS platform that would allow for regional data sharing and the generation of spatiotemporal epidemic forecasts. Stakeholders identified a 3-month forecast of arboviral illness as the optimal time frame for an epidemic forecast. CONCLUSIONS: These findings support the creation of interdisciplinary and intersectoral 'communities of practice' and the co-design of climate services for the Caribbean public health sector. By fostering the effective use of climate information within health policy, research and practice, nations will have greater capacity to adapt to a changing climate.

Zika Virus Outbreak, Barbados, 2015-2016.

Barbados is a Caribbean island country of approximately 285,000 people, with a thriving tourism industry. In 2015, Zika spread rapidly throughout the Americas, and its proliferation through the Caribbean islands followed suit. Barbados reported its first confirmed autochthonous Zika transmission to the Pan American Health Organization in January 2016, a month before the global public health emergency was declared. After detection of suspected Zika cases on Barbados in 2015, 926 individuals were described as suspected cases, and 147 laboratory-confirmed cases were reported through December 2016, the end of the most recent epidemiological year. In this short report, we describe the epidemiological characteristics of 926 clinical case records that were originally suspected as cases of Zika, and which were subsequently sent for testing and confirmation; 147 were found positive for Zika, using reverse transcription-polymerase chain reaction methods, another 276 tested negative, and the remaining 503 were either pending results or still in the suspected category. Women were represented at about twice the rate of men in case records where gender was reported (71.9%), and confirmed cases (78.2%), and 19 of the confirmed positive cases were children under the age of 10.

Epidemiological trends and clinical manifestations of Dengue among children in one of the English-speaking Caribbean countries.

BACKGROUND: The epidemiology and clinical presentation of dengue fever among children in the Caribbean is poorly characterized. We therefore studied the epidemiology, clinical presentation, immunological characteristics, morbidity and mortality from dengue virus infection among children in Barbados, one of the English-speaking Caribbean countries. METHOD: In this population-based, retrospective descriptive study, we screened all children on the island up to the age of 16 years who presented over a 10-year period (January 2000 through December 2009) with febrile illness and suspected dengue virus infection (n = 1809). We report on all the laboratory-confirmed cases of dengue (702/1809), for 545 of which we had complete clinical data. RESULTS: The annual incidence of dengue virus infection among children ranged between 0.29 and 2.92 cases/1000 children, with most cases seen during October through January. Children presented with undifferentiated fever (287/545, 53%), classical dengue fever (225/545, 41%), dengue hemorrhagic fever (15/545, 3%) and expanded dengue syndrome (i.e. severe involvement of liver, kidneys, brain, heart, or other unusual manifestations) (18/545, 3%). In most cases (73%), the infection was secondary. Thirty per cent of cases were diagnosed among hospitalized children and the overall crude mortality rate was 0.3%. CONCLUSION: Our study for the first time describes the epidemiology and disease characterization of dengue in Barbados, and quantifies the morbidity and mortality among children for this rapidly emerging public health problem in the Caribbean sub-region of the Americas.

Frequency of detection of immunoglobulins of Toxoplasma gondii, Leptospira spp., and Brucella abortus in livestock/farm and abattoir workers in Trinidad.

Toxoplasma gondi, Leptospira spp., and Brucella abortus are all established parasitic and bacterial zoonoses that manifest themselves in several forms of human diseases. They have been associated with occupational exposures, particularly amongst workers associated with livestock farms. The primary objectives of this study were to determine the seroprevalence of T. gondii immunoglobulin M (IgM) immunoglobulins (serum antibodies), Leptospira IgM immunoglobulins, and B. abortus IgG immunoglobulins, suggestive of acute or chronic infections, in livestock/farm and abattoir workers in Trinidad, and to relate to risk factors. Blood samples were collected from 394 consenting livestock/farm workers and 99 abattoir workers across the island of Trinidad. Serological status was determined by enzyme immunoassay (EIA) for T. gondii IgM, enzyme-linked immunosorbent assay (ELISA) for Leptospira IgM immunoglobulins, and buffered plate agglutination test (BPAT) and competitive ELISA for B. abortus IgG immunoglobulins. Of 394 apparently healthy livestock/farm workers sampled, 150 (38.1%) were seropositive for T. gondii IgM immunoglobulins, compared with 44 (44.4%) of 99 abattoir workers (p > .05; χ(2) test). Five (1.3%) of 371 and 1 (1.0%) of 99 livestock/farm and abattoir workers respectively were positive for Leptospira IgM immunoglobulins. All samples from livestock/farm workers and abattoir workers were negative for B. abortus immunoglobulins. None of the risk factors investigated was statistically significantly (p > .05; χ(2) test) associated with T. gondii and Leptospira spp. infections.