Building capacity of healthcare professionals and community members to address climate and health threats in The Bahamas: Analysis of a green climate fund pilot workshop.

Climate change is a preeminent threat to health and health systems in The Bahamas. Climate and health resilience depends upon a knowledgeable and coordinated healthcare system and workforce that is highly connected and coordinated with a knowledgeable and empowered community. We present the methodology and results of a novel educational workshop, designed to increase the knowledge and awareness of health care professionals and community members with the goal of empowering them to engage in climate mitigation and adaptation strategies. Following the training, participants demonstrated increased knowledge of the causes of climate change, health exposures, climate-sensitive diseases, and vulnerable populations relevant to The Bahamas. Further, participants reported high levels of willingness and readiness to tackle climate change and its health consequences. Results from this workshop suggest that such a model may serve as a guide for building grass-roots resilience in communities worldwide.

Regionalization as an approach to regulatory systems strengthening: a case study in CARICOM member states.

Improving basic capacities for regulation of medicines and health technologies through regulatory systems strengthening is particularly challenging in resource-constrained settings. "Regionalization"-an approach in which countries with common histories, cultural values, languages, and economic conditions work together to establish more efficient systems-may be one answer. This report describes the Caribbean Regulatory System (CRS), a regionalization initiative being implemented in the mostly small countries of the Caribbean Community and Common Market (CARICOM). This initiative is an innovative effort to strengthen regulatory systems in the Caribbean, where capacity is limited compared to other subregions of the Americas. The initiative's concept and design includes a number of features and steps intended to enhance sustainability in resource-constrained contexts. The latter include 1) leveraging existing platforms for centralized cooperation, governance, and infrastructure; 2) strengthening regulatory capacities with the largest potential public health impact; 3) incorporating policies that promote reliance on reference authorities; 4) changing the system to encourage industry to market their products in CARICOM (e.g., using a centralized portal of entry to reduce regulatory burdens); and 5) building human resource capacity. If implemented properly, the CRS will be self-sustaining through user fees. The experience and lessons learned thus far in implementing this initiative, described in this report, can serve as a case study for the development of similar regulatory strengthening initiatives in resource-constrained environments.

Regionalization as an approach to regulatory systems strengthening: a case study in CARICOM member states / La regionalización como medio para fortalecer los sistemas de reglamentación: estudio de caso en los estados miembros del CARICOM

Improving basic capacities for regulation of medicines and health technologies through regulatory systems strengthening is particularly challenging in resource-constrained settings. “Regionalization”—an approach in which countries with common histories, cultural values, languages, and economic conditions work together to establish more efficient systems— may be one answer. This report describes the Caribbean Regulatory System (CRS), a regionalization initiative being implemented in the mostly small countries of the Caribbean Community and Common Market (CARICOM). This initiative is an innovative effort to strengthen regulatory systems in the Caribbean, where capacity is limited compared to other subregions of the Americas. The initiative’s concept and design includes a number of features and steps intended to enhance sustainability in resource-constrained contexts. The latter include 1) leveraging existing platforms for centralized cooperation, governance, and infrastructure; 2) strengthening regulatory capacities with the largest potential public health impact; 3) incorporating policies that promote reliance on reference authorities; 4) changing the system to encourage industry to market their products in CARICOM (e.g., using a centralized portal of entry to reduce regulatory burdens); and 5) building human resource capacity. If implemented properly, the CRS will be self-sustaining through user fees. The experience and lessons learned thus far in implementing this initiative, described in this report, can serve as a case study for the development of similar regulatory strengthening initiatives in resource-constrained environments.

El mejoramiento de la capacidad básica para la reglamentación farmacológica mediante el fortalecimiento de los sistemas de reglamentación plantea un reto especialmente difícil en contextos de escasos recursos. Una posible solución radica en la “regionalización”, proceso según el cual países con un mismo legado histórico, cultural y lingüístico y con situaciones económicas semejantes colaboran entre sí con objeto de establecer sistemas más eficientes. En el presente informe se describe el Sistema de Reglamentación del Caribe (SRC), iniciativa de regionalización que se está poniendo en marcha en los países de la Comunidad y el Mercado Común del Caribe (CARICOM), pequeños en su mayoría. La iniciativa representa una medida innovadora por fortalecer los sistemas de reglamentación en el Caribe, donde la capacidad existente es más modesta que en otras subregiones de las Américas. En el concepto y diseño de la iniciativa hay elementos y pasos destinados a fomentar la sostenibilidad en contextos de escasos recursos. Estos consisten en aprovechar las plataformas ya existentes para la cooperación, gobernación e infraestructura centralizadas; fortalecer las capacidades de reglamentación que puedan tener la mayor incidencia sobre la salud pública; incorporar políticas que fomenten la confianza en los organismos de reglamentación; modificar el sistema para alentar a la industria a comercializar sus productos en el CARICOM (por ejemplo, utilizando un punto de entrada centralizado para aligerar las cargas reglamentarias); y fortalecer la capacidad en materia de recursos humanos. Si se pone en práctica adecuadamente, el SRC se financiará a sí mismo con las cuotas de los usuarios. La experiencia y las enseñanzas extraídas hasta el momento con la puesta en marcha de esta iniciativa, que se describen en el presente informe, pueden ser útiles como estudio de caso para la formulación de iniciativas afines orientadas a fortalecer la capacidad de reglamentación en entornos de pocos recursos.

Salud internacional y nuevas formas de asociación: el Diálogo Multipartito y el Foro de Socios / International health and new forms of association: the Multipartite Dialogue and the Partners Forum

Se describen y analizan dos iniciativas de cooperación en salud pública en las cuales participan representantes de la sociedad civil, la academia, el sector público y sector privado de las Américas. Una de ellas -el Diálogo Multipartito- promueve la aproximación intersectorial en su más amplio concepto, mientras que la otra -el Foro de Socios- si bien representa una iniciativa institucional, asigna mayor atención a las enfermedades crónicas no transmisibles. Ambas constituyen un llamado a la acción para los gobiernos y ofrecen alternativas para enfrentar más efectivamente los problemas de la salud regional.

Two cooperative public health initiatives involving representatives of civil society, academia, and the public and private sectors of the Americas are described and analyzed. One of them-the Multipartite Dialogue-promotes an intersectoral approach in its broadest sense, and the other-the Partners Forum-while it represents an institutional initiative, pays particular attention to chronic noncommunicable diseases. Both are a call to action for governments and offer alternatives to tackle regional health problems more effectively.

Más allá del ámbito clínico en el cuidado de la hipertensión arterial / High blood pressure care: beyond the clinical setting

Se contrastaron las recomendaciones contenidas en el séptimo informe del Comité nacional conjunto para la prevención, detección, evaluación y tratamiento de la hipertensión arterial (JNC 7) con un artículo reciente de Aram V. Chobanian, quien fuera presidente del JNC 7. El propósito fue identificar cuáles son los cambios propuestos por este autor y cómo podrían afectar la actuación clínica, así como sus implicaciones en los servicios sanitarios y la salud pública. El JNC 7 y el mencionado artículo coinciden en todos los puntos esenciales, con la excepción de que este último es más flexible en la utilización de diuréticos para iniciar el tratamiento de la hipertensión arterial (HTA). Se considera que la atención de las enfermedades crónicas debería inscribirse en sistemas de salud con un enfoque de atención primaria, donde la epidemiología de tales enfermedades y los avances en la prevención ofrecen una excelente ocasión para rediseñar y hacer más efectivos los servicios de salud. La HTA, como un problema poblacional, requiere de intervenciones sanitarias orientadas no solo a conjurar los daños sino a modificar sus determinantes etiológicos. El desafío es reconocer que un enfoque integrado de medicina clínica, servicios de salud y salud pública, proporcionaría una atractiva oportunidad para interrumpir y prevenir el continuo y costoso círculo que supone el manejo de la HTA y sus complicaciones.

The recommendations from the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) were compared with those of a recent article by Aram V. Chobanian, Chairman of the JNC 7. The purpose was to identify the changes that this author proposed and determine how they might affect clinical work, as well as the health services and public health implications. The JNC 7 and the article in question coincide on all essential points, except that the article is more flexible when it comes to the use of diuretics at the start of treatment for high blood pressure. Chronic disease management should take place in health systems with primary care approach, where the epidemiology of such diseases and scientific advances in prevention offer an excellent opportunity for redesigning the health services and making them more effective. High blood pressure, as a public health problem, demands health interventions aimed not only at reducing harm but modifying its etiologic determinants. The challenge is to recognize that an integrated approach to clinical medicine, health services, and public health would offer an attractive opportunity to interrupt and prevent the continuous and costly vicious circle that managing high blood pressure and its complications implies.

A survey of hepatitis B among health workers in Jamaica - abstract

A convenience sample of 1537 health staff in Jamaica were surveyed in 1990/91 for hepatitis B markers and/or exposure to blood or hepatitis. Antibodies to either hepatitis B surface antigen (HBsAg) or hepatitis B core (HBc) were found in 19.8 per cent of 817 persons tested. HBsAg was found in 5.3 per cent persons tested. One or more needlestick accidents were reported by 60 per cent of the sample and blood or liquor splashing on the face was reported by 48 per cent. Jaundice and hepatitis was reported by 1.2 per cent and 3.5 per cent respectively. Prevalence of antibodies to hepatitis B virus (HBV) increased with age (p = 0.004) and years of service (p = 0.28) while HBsAg carrier status was associated with years of service (p = 0.039). Males were more likely to have antibodies to HBV than females (Odds Ratio 1.63, 95 per cent, CI 0.98 - 2.71). This survey reaffirms the importance of health workers being immunized with hepatitis B vaccine and adhering rigorously to universal precautions in patient care and laboratory practice (AU)

Case control study of a cholera outbreak in Guyana - abstract

An outbreak of cholera occurred, beginning November 3, 1992 in Region 1 in the northwest of Guyana, initially centred around the town of Mabaruma. By November 17, 1992, 168 cases had occurred with 38 admissions and three deaths. The majority of cases were > 5 yrs. old with many of the most seriously affected being aged > 25 yrs. To determine likely means of transmission, an unmatched case-control study of 33 cases and 25 hospital-based controls was rapidly conducted. The main results for different exposures and protective factors are summarized in the Table given. These findings confirmed previous suspicions and were used to develop specific preventive messages for the preparation of food and use of water for drinking (AU)

Measles surveillance in the English-speaking Caribbean and Suriname: a key strategy in the campaign to eliminate indigenous measles by 1995 - abstract

In 1988, the Caribbean Health Ministers declared the goal of indigenous measles elimination by 1995 in the light of the success of measles vaccination programmes, introduced in 1982, in decreasing disease occurrence. Prior to 1982, measles occurred continuously in larger territories and Caribbean-wide epidemic activity occurred every 3 to 4 years; the last epidemic being in 1989/90. One of the key strategies for measles elimination was a mass immunization campaign conducted in May - June 1991 with a 91.4 per cent vaccination uptake rate among the target population aged 9 months - 15 years. Nine countries achieved coverage rates of > 95 per cent. This was followed by the introduction of an active and sensitive surveillance system on 1st September, 1991 and up to October 31, 1992, 504 suspected cases of measles were reported. However, there were only two (2) confirmed cases (from Barbados - one indiginous and one imported) and 124 compatible cases. Thus, in the 14 months since the launch of the new surveillance system, one case of indigenous measles has been indentified. Logically, the combination of widespread epidemic activity in 1989/90, followed by a very successful mass vaccination campaign in 1991, has enormous potential for breaking all chains of transmission in a population. Continued high-quality surveillance will be necessary to certify elimination but transmission appears to have been interrupted throughout the English-speaking Caribbean. If this is possible in the Caribbean, across a wide variety of territories, then global eradication is one step closer to being a reality (AU)

Surveillance and management of sylvatic yellow fever in Trinidad (1988-1989) - abstract

Howler monkey (Aloutta sp) deaths in the Southeastern forests of Trinidad were reported in December, 1988. This paper reports the laboratory and field investigations and preventive measures which were undertaken, in view of the known association between such deaths and yellow fever (YF) activity. A total of 47,640 adult mosquitoes were captured in several forest regions in Trinidad during the period December 1988 to October, 1989. Mosquitoes were identified, pooled and processed for virus isolation. Blood and organs from 5 dead Howler monkeys submitted between December 1988 and March, 1989 were examined for the presence of YF virus. Virus isolation was done by innoculation of material in AP61 (Ades pseudo-scutellaris) tissue culture and in 2-day-old Swiss albino mice, followed by identification of YF isolates by immunoflourescence, using monoclonal antibody and standard mouse neutralization tests, respectively. Fourty-four species of mosquito belonging to 14 genera were identified. From 654 mosquito pools, 6 YF isolates were obtained from only 2 species: five isolates from haemagogus janthinomys (December, 1988) and 1, for the first time locally, from Sabethes chloropterus (January, 1989). YF virus was isolated from blood and organs of 2 Howler monkeys captured on February 22 and March 2, 1989. There were no human cases of YF. Yellow fever activity appeared to be confined to the southeast part of the island. Preventive measures included mass targeted YF immunization (400,000 doses administered in 3 months), intensified vector control operations and reduced human contact with forest mosquitoes by the existing ban on hunting (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)

Chlamydia trachomatis in antenatal women at Mount Hope Women's Hospital in Trinidad and Tobago: prevalence and perinatal transmission

Chlamydia trachomatis infection is being increasingly recognized as an important public health problem worldwide. The prevalence and rate of perinatal transmission of chlamydia was examined in 200 women attending antenatal clinic at the Mt. Hope Women's Hospital using tissue culture (TC), ELISA and fluorescent antibody (FA) methods. 27 (13.6 percent) women were found to be chlamydia positive by TC. 13 of the babies born to these mothers were also found to be positive, giving a vertical transmission rate of 48 percent. Compared to TC, the ELISA test was 96 percent sensitive and 100 percent specific while FA was 67 percent sensitive and 99 percent specific. Chlamydial infection was significantly associated (p<0.001) with being of Afro-Trinidadian descent, age <25 years, being unmarried and having two or more sexual partners in the past five years. The association with ethnicity could be explained on the basis of numbers of sexual partners and marital status. Chlamydia is often asymptomatic and no association was found with a history of previous STD, vaginitis or lower abdominal pain. It is recommended that women attending antenatal, family planning and STD clinics be screened for chlamydia infection and treated, together with their sexual partners, as an effective way of prevention. Enhanced chlamydia surveillance and strengthened laboratory capabilities are also recommended. (AU)