Climate Factors as Important Determinants of Dengue Incidence in Curaçao.

Macro- and microclimates may have variable impact on dengue incidence in different settings. We estimated the short-term impact and delayed effects of climate variables on dengue morbidity in Curaçao. Monthly dengue incidence data from 1999 to 2009 were included to estimate the short-term influences of climate variables by employing wavelet analysis, generalized additive models (GAM) and distributed lag nonlinear models (DLNM) on rainfall, temperature and relative humidity in relation to dengue incidence. Dengue incidence showed a significant irregular 4-year multi-annual cycle associated with climate variables. Based on GAM, temperature showed a U-shape, while humidity and rainfall exhibited a dome-shaped association, suggesting that deviation from mean temperature increases and deviation from mean humidity and rainfall decreases dengue incidence, respectively. Rainfall was associated with an immediate increase in dengue incidence of 4.1% (95% CI: 2.2-8.1%) after a 10-mm increase, with a maximum increase of 6.5% (95% CI: 3.2-10.0%) after 1.5 month lag. A 1 °C decrease of mean temperature was associated with a RR of 17.4% (95% CI: 11.2-27.0%); the effect was inversed for a 1°C increase of mean temperature (RR= 0.457, 95% CI: 0.278-0.752). Climate variables are important determinants of dengue incidence and provide insight into its short-term effects. An increase in mean temperature was associated with lower dengue incidence, whereas lower temperatures were associated with higher dengue incidence.

Global health and transfusion medicine: education and training in developing countries.

Education and training in transfusion medicine have improved over the past decade in developing countries but are still generally deficient for the purpose of maintaining the safety of the global blood supply. In 2009, the World Health Organization global database on blood safety indicated that only 72% of countries in the world were able to meet their training needs necessary for maintaining the safety of their local blood supply. Educational approaches in transfusion medicine vary widely between continents and world regions. In this article, we summarize a session on global health education and training in developing countries that took place at the 2012 AABB conference. The panel consisted of transfusion representatives from South America (Brazil), Asia (China), Africa (South Africa), and the Caribbean (Curaçao), as well as a description of capacitation issues in postearthquake Haiti and the pivotal role of the US President's Emergency Plan for AIDS Relief (PEPFAR) in transfusion training and education in Africa. We present here summaries of each of these panel presentations.

High incidence of intermittent care in HIV-1-infected patients in Curaçao before and after starting cART.

Retention in care is one of the major challenges to scaling up and maximizing the effectiveness of combination antiretroviral therapy (cART). High attrition rates have been reported in the Caribbean region, varying from 6% to 23%. We studied the incidence of and risk factors for intermittent care in a cohort of adult HIV-1-positive patients, who entered into care in Curaçao between January 2005 and July 2009. A total of 214 therapy-naïve HIV-1-infected patients aged 15 years or older, entered HIV care between January 2005 and July 2009. Intermittent care was defined as at least one period of 365 days or longer in which there was no HIV care contact in Curaçao. Cox regression models were used to identify characteristics associated with time to intermittent care. In all, 203 (95%) patients could be classified as having intermittent or continuous care. The incidence of intermittent care before starting cART was 25.4 per 100 person years observation (PYO), whilst it was 6.1 per 100 PYO after starting cART. Being born outside Curaçao was associated with intermittent care before and after starting cART. Time from diagnosis to entry into care was an independent predictor for intermittent care before starting cART. Younger age was independently associated with intermittent care after starting cART. Half of the patients returned to care after intermitting care. Upon returning to care, median CD4 count was 264 cells/mm(3) (IQR, 189-401) for those who intermitted care before starting cART, and 146 cells/mm(3) (IQR, 73-436) in those who intermitted care after starting cART. In conclusion, the incidence of intermitting care is high in Curaçao, especially before starting cART, and intermitting care before starting cART is an independent predictor for starting cART late.

Optimizing chronic HIV care in the Dutch Caribbean: a questionnaire based study on experience and perception of healthcare workers.

OBJECTIVE: Human immunodeficiency virus (HIV) infection has become a chronic disorder for which adaptation of current healthcare practices is needed. In Curaçao, a new organization of chronic HIV care is being set up based on task shifting in which healthcare workers (HCWs) will deliver HIV care more prominently within the primary healthcare system. In preparation for implementation of the proposed task-shifting model, we investigated the perception of HCWs regarding existing HIV care in Curaçao and the need for training in HIV/AIDS among HCWs. SUBJECTS AND METHODS: An in-depth questionnaire based study was used. Nineteen HCWs of seven different cadres were interviewed. The questionnaire constituted four sections: quality of existing HIV care, respondents own knowledge and willingness to be trained, need for training in HIV/AIDS and preferred educational approaches. RESULTS: Quality of existing HIV services in Curaçao is considered acceptable but needs improvement mainly to facilitate integration of chronic HIV care. All respondents indicated that training in HIV/AIDS is needed among HCWs in Curaçao, especially for nurses and general practitioners. All were willing to participate in training with varying amounts of time to be spent. Training should be tailored to the level of expertise of HCWs and to the role a HCW is expected to have in the new healthcare delivery framework. CONCLUSION: There is need for training to ensure the effective integration of chronic HIV care into the existing healthcare delivery system in Curaçao.There is a willingness and need in all cadres for training with e-learning as a preferred educational tool.

Epidemiology of febrile diseases in the emergency department of a Caribbean island: the Curaçao experience.

OBJECTIVE: The aetiology of febrile diseases in tropical countries often remains poorly characterized. We aim to describe the aetiology and outcome of febrile illnesses at the Emergency Department (ED) in Curaçao. METHODS: From April 2008 - April 2009, all adult febrile patients (T> 38.5 degrees C) at the ED of the St Elisabeth Hospital, Curaçao, Netherlands Antilles, were included. Clinical data were recorded, routine laboratory measurements and blood cultures were taken. Final diagnoses were made at discharge by an independent physician and in retrospect by the main investigator RESULTS: Four hundred and three patients were included: 223 patients (55.6%) were hospitalized, 32 patients (7.9%) died and 18 patients (4.5%) were admitted to the Intensive Care Unit. In 129 febrile patients (32.0%), infection was proven; 84.4% of patients had bacterial (29.0% urinary tract infection, 23.2% pneumonia infection), 5.6% viral and 10.0% parasitic or fungal infections. Twenty-one patients (5.2%) were discharged with a non-infectious diagnosis and 172 patients (42.7%) without a clear diagnosis. CONCLUSION: A high mortality rate of 7.9% was observed. We found a high prevalence of bacterial infections, with pneumonia and urinary tract infections as the most common causes of fever. One in 20 patients did not have an infectious disease.

A case study of the implementation of a competency-based curriculum in a Caribbean teaching hospital.

OBJECTIVE: Several teaching hospitals are currently modifying their curriculum to comply with the changing demands in medical education. As a result, we decided to evaluate whether a competency-based curriculum implemented in a Caribbean teaching hospital fulfilled the requirements as defined by the CanMEDS framework. METHODS: We made use of a triangulation method in the survey to obtain information on the educational process. Two separate methods were used consisting of site visits by visiting professors and a medical educator. The focus was on the structure, content and assessments of the educational activities. RESULTS: Major recommendations included increased involvement of medical specialists in the educational activities in the clinical workplace. There was need for improvement of communication between medical specialists, patients, nurses, trainees and residents. Overall, improvements were observed in the structure of clinical rotations and content of the training programme. CONCLUSION: The implemented assessment programme provided necessary information for effective evaluation of the competency-based curriculum. We were able to identify new and feasible methods for improving the curriculum in our educational setting.

[Kidney transplant program facilitated by airlift between the Netherlands Antilles and the Netherlands; 1998-2001]. / Niertransplantatieprogramma op de Nederlandse Antillen door een luchtbrug met Nederland; 1998-2001.

OBJECTIVE: To describe the results of a structured kidney-transplantation programme available to dialysis patients in Curaçao (Dutch Caribbean), involving transplantation in the Netherlands and follow-up in Curaçao. DESIGN: Descriptive. METHOD: In 1998, a joint venture was begun with the Academic Medical Center (AMC) in Amsterdam, the Eurotransplant Foundation, the Dutch Transplantation Working Party and the Diagnostic Division of the Sanquin Foundation in Amsterdam, the Netherlands. Its aim was to achieve a structural kidney transplantation programme for patients in the Dutch Caribbean in general and patients in Curaçao in particular. An airlift programme between Curaçao and the AMC was instituted. RESULTS: Between 1998-2001 19 patients underwent a kidney transplant, three of which failed. In most of the transplants the cold ischaemia time was less than 48 hours; the average cold ischaemia time was 32 hours. All patients returned to the Antilles within 3 months where their treatment was continued. Post-transplantation follow-up was on average 13.9 months (limits 3-36); three patients died.

Two common endoglin mutations in families with hereditary hemorrhagic telangiectasia in the Netherlands Antilles: evidence for a founder effect.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant bleeding disorder characterized by localized angiodysplasia. Mutations in either of two genes, endoglin or ALK-1, can cause HHT. Both genes encode putative receptors for the transforming growth factor-beta superfamily of ligands. Many mutations in each gene have been identified in HHT kindreds from around the world, and with few exceptions mutations are unique and family specific. The prevalence of HHT in the Leeward Islands of the Netherlands Antilles is possibly the highest of any geographical location. We wished to establish whether this high prevalence is due to a genetic founder effect or to multiple mutational events. HHT kindreds from the Netherlands Antilles and The Netherlands were screened for mutations in the two genes associated with HHT. Haplotype analysis of a 5-cM region on chromosome 9 flanking the endoglin gene revealed three distinct disease haplotypes in the ten Antillean families studied. Seven of these families share a splice-site mutation in exon 1 of endoglin. Two other Antillean families share a missense mutation in exon 9a of endoglin. This mutation was also found in a Dutch family that shares the same disease haplotype as the Antillean families with this mutation. Thus it appears that HHT in the Netherlands Antilles is due to a limited number of ancestral mutations in the endoglin gene, and that one of these mutations was introduced into the African slave population by a Dutch colonist. The limited scope of mutations suggests that a presymptomatic screening program for HHT would be feasible in this population.

Enhanced sVCAM-1 levels in paediatric patients with sickle cell disease

Recently, several reports have shown endothelial activation to play an important role in the pathophysiology of sickle cell vaso-occlusion. We measured serum soluble VCAM-1 and soluble ICAM-I levels in steady state paediatric sickle cell patients. TNF, an endothelial activating cytokine, was also measured. sVCAM-I levels were increased as compared to age, sex and race-matched controls (p=0.002), whereas sICAM-I levels were not significantly enhanced. TNF levels were also elevated in paediatric sickle cell patients as compared to controls (p=0.01). These results show that endothelial activation is already manifest at a very young age in sickle cell patients, probably resulting from enhanced endothelial activating cytokines, such as TNF.(AU)

Folic acid status of paediatric patients with sickle cell disease

We investigated whether paediatric patients with sickle cell disease (9ñ4 years; 27 HbSS; 19 HbSC) have different folic acid status compared with age-, sex-and race-matched HbAA controls (n=20), and whether their folic acid status can be improved by folic acid supplementation. The patients were supplemented with vitamins B6 and B12 during one week and with folic acid during the next week. Circulating folic acid, homocysteine, vitamin B6 and vitamin B12 levels were measured at baseline (patients and controls), after 1 and 2 weeks (patients). The patients had similar folic acid, vitamin B6 and vitamin B12, but higher homocysteine levels, compared with HbAA controls (12.7ñ4.5 vs 10.9ñ3.5 mmol/l;p=0.04). Vitamin B6 and B12 supplementation did not change their homocysteine levels, but folic acid supplementation caused a 52 percent reduction (to 5.7ñ1.6). We conclude that patients with sickle cell disease have adequate vitamin B6 and B12 status, but suboptimal folic acid status. They may benefit from folic acid supplementation to reduce their high risk for endothelial damage.(AU)