Poliomyelitis era in Trinidad from 1940 to 1972 and beyond: Implications for effective global health governance for its eradication.

BACKGROUND: Acute poliomyelitis (APM/polio) is a viral infection caused by the polio virus that continues to have a fascinating social and economic impact on countries throughout the world. Humans acquire the virus by close personal contact with transmission occurring through the fecal-oral route. The majority of poliovirus infections results in no illness or produces only self-limited symptoms, however in approximately 5% of infected patients flaccid paralysis of the limbs can occur and 1% can die. Although APM is no longer a feared disease mainly due to the development of effective vaccines, its eradication remains elusive. METHODS: The aim of this study is to review the historical impact of APM in Trinidad. A retrospective analysis of all cases occurring from 1939 to 1972 was undertaken. Data for the study were derived from two sources the Annual Statistical Reports of the Ministry of Health 1972-2000 and the epidemiological publications of the League of Nations Health Organization and the World Health Organization. RESULTS: There were four outbreaks of APM in Trinidad 1941, 1942, 1954, and 1972. After the final outbreak in 1972, APM was eradicated not only from Trinidad but also all the countries of the Americas mainly through the effective use of the oral polio vaccine. CONCLUSION: Polio has brought together international agencies, governments, and the people to build an effective public health system around a common vision for health and wellbeing. The polio eradication and endgame strategic plan represents a major milestone in polio eradication developed by global polio eradication initiative. The initiative would still benefit from adopting some of the best practices in governance from other organizations in the global health sector.

Towards the Elimination of Syphilis in a Small Developing Country.

Objective. To describe the current epidemiological features of syphilis and congenital syphilis in Trinidad, 2009-2012. Methods. All laboratory confirmed syphilis cases diagnosed through a vertical program in the Ministry of Health, between 1/1/2009 and 31/12/2012, were identified. All relevant data were collected including address which was geocoded and mapped using ArcGIS 10.0 (Esri). Both spatial techniques and standardized incidence ratios were used to determine hot spots. Results. The annual cumulative incidence rate for syphilis remains high varying from 39 per 100 000 population in 2009 to 29 per 100 000 in 2012. We identified 3 "hot spots," in urban areas of Trinidad. Young men and particularly young women in childbearing age 15-35 living in urban high density populations were commonly infected groups. Conclusion. The incidence of syphilis continues to be very high in Trinidad. New initiatives will have to be formulated in order to attain the global initiative to eradicate syphilis by 2015.

Challenges to the control of breast cancer in a small developing country.

OBJECTIVE: The aim of this study is to determine the clinicopathological features of breast cancer in two dedicated cancer treatment centers in north Trinidad. The histological types and stage at presentation were also investigated. DESIGN AND METHODS: A retrospective cohort design was used; data were collected from a review of medical records of patients meeting the entry criteria. Clinical and demographic data were extracted. RESULTS: A total of 640 patients were selected for the study and were available for the analysis. The annual cumulative incidence rate of breast cancer for the calendar years 2010 and 2011 in north Trinidad was 32.4 per 100,000 and 24.6 per 100,000 of the population. The age group between 51-60 years had the highest proportion of cases of breast cancer. There was a significant ethnic disparity in the occurrence of breast cancer, as it was more common in people of African origin than among South East Asians. Surgery and chemotherapy were the major interventions employed. CONCLUSION: Breast cancer prevalence continues to be high in Trinidad; we provide evidence of the extent of and the degree of sophistication required to care for patients with breast cancer in a health care system in a small developing country.

Assessing the HIV rapid test in the fight against the HIV/AIDS epidemic in Trinidad.

OBJECTIVE: To evaluate the human immunodeficiency virus (HIV) rapid test as an effective tool in the response to the HIV/acquired immunodeficiency syndrome (AIDS) epidemic in Trinidad. DESIGN AND METHODS: The study is comprised of a retrospective analysis of data collected from May 2008 to July 15, 2011 and a prospective arm of those tested during July 18, 2011 - August 30, 2011. During the prospective phase, blood samples were tested using rapid tests manufactured by Inverness Medical Innovation and Trinity Biotech followed by an enzyme-linked immunosorbent assay test, irrespective of the results of the rapid test. A structured questionnaire was administered to collect demographic data and risk behaviors. The study was conducted in one randomly selected primary health care facility of the eight that offered same-day HIV testing in Trinidad. RESULTS: A total of 297 persons participated in the prospective arm of the study and the rapid test was found to have a sensitivity of 100% and a specificity of 99.6%. Females and those aged 20-29 years were most likely to participate. Over the study period, the number of persons who received rapid tests increased but the prevalence of positive HIV test results decreased from 4.4% in 2008 to 2.1% in 2011. The main reasons for being tested were curiosity (38%), results being obtainable the same day (27%), and confidentiality (13%). Approximately 50% of respondents reported more than one sex partner in the previous year while 14% used condoms regularly. CONCLUSION: People need to know their own HIV status and that of their partners to make healthy decisions about sexual behavior. At the health facility studied, 2.6% of people who took the HIV rapid test were HIV positive.

Are teenagers at risk for developing cardiovascular disease in later life?

BACKGROUND: The aim of this study is to measure the occurrences of the following risk factors: tobacco use, levels of physical activity, levels of physical inactivity, and body mass index (BMI) among adolescents in Trinidad. METHODS: A two-stage random sampling process was used to select schools and students. Data were collected using a pretested self-administered questionnaire and included age, gender, ethnicity, tobacco use, levels of physical activity, levels of physical inactivity, BMI, and frequency of fast food consumption. RESULTS: Overall, 44.6% of the 1896 adolescents already had more than two risk factors associated with cardiovascular disease (CVD). The most prevalent risk factor was the consumption of fast food (79.8%), while the least was smoking (12.0%). Out of the 75.4% physically active students, 47.6% spent more than 30 min in daily physical activity. In addition, 30.4% of the study population was overweight and obese, with the majority being 14 years of age (p=0.003). Overall, the overweight and obese students spent a significant amount of time watching television, playing video/computer games and talking on the phone, and frequently consumed fast food (p<0.001). CONCLUSION: The study found a significant number of teenagers in Trinidad presenting with more than two risk factors that may lead to CVD. Based on previous research, these findings have undoubtedly placed the students well within the models used to predict heart disease later in life.

Is it time to replace 24-hour urinary albumin excretion (UAE) assessment in Trinidad and Tobago

OBJECTIVE The aim of this study is to compare albuminuria measured by conventional 24-hour urine collection and by spot urine albumin and by determining ACR, in a spot sample of urine. METHODS: A first morning spot sample and 24 hour urine samples were collected from 64 subjects, irrespective of the prevailing pathology. The urinary albumin and creatinine in both the spot and 24 hour urine samples was analyzed using the fully automated chemistry analyzer. RESULTS: Of the 64 participants studied the 24 hour albumin varied from 30-3000 gm, the interquartile range 450-2814 mg. The sensitivity and specificity of the spot urine sample was 81.3% (95% CI 70.9-91.7) and 83.3% (95% CI 76.6-92). CONCLUSION: ACR did not provide any advantage over microalbumin measurement alone and in fact there was satisfactory agreement between the two measurements. ACR in addition requires a higher laboratory effort therefore in a low resource setting microalbumin measurement alone is the more convenient screening method in routine clininical practice especially in the developing world.

Prostate cancer survival in Trinidad: Is PSA a prognostic factor?

BACKGROUND: Prostate cancer is the most common malignancy among men in the western hemisphere, including Trinidad and Tobago. The aim of this study is to describe the epidemiological features of prostate cancer among patients admitted to a tertiary level teaching hospital during 2002 to 2005. We assessed the long-term survival of patients with prostate cancer and the epidemiology of the disease. METHODS: We reviewed the admissions data for the period 2002-2005. Demographic, clinical and outcomes (survival or death) data were collected and analysed, using SPSS version 16. Statistical analysis included Kaplan-Mier survival analysis, Cox regression models and the log-rank test. A p value of <0.05 was considered statistically significant. RESULTS: Of the 1250 cases reviewed, 242 participants were selected. Patients of African ancestry, older than 60 years and a Gleason score greater than 7 had an increased risk of mortality. Patients with prostate-specific antigen (PSA) ≥100 ng/L had a 3-fold increased risk of mortality. Survival rates declined between 2002 and 2005. CONCLUSION: This is the first study of its kind to demonstrate survival rates among patients with prostate cancer in Trinidad. The following epidemiological features were identified: average age of occurrence of 71 years, ethnic disparity with higher occurrence in African men than all other ethnic groups and a PSA of >100 ng/dL. These features were associated with a 3-fold higher risk of death. A Gleason score of 8 to 10 was also associated with lower survival rates.

The occurrence of left ventricular hypertrophy in normotensive individuals in a community setting in North-East Trinidad.

OBJECTIVE: The purpose of this study is to determine primarily the occurrence of left ventricular hypertrophy (LVH) in normotensive Trinidadians. DESIGN AND METHODS: Enrollment into the study required participants to have normal blood pressure (≤ 140/90) using the JNC 7 (The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) classification, free of type 2 diabetes, as well as no existing LVH. Upon entry into the study, participants were first screened for LVH using a standard 12-lead electrocardiogram (ECG), using the Sokolow-Lyon index and the Cornell index. ECHO was used to confirm or refute the diagnosis of LVH. RESULTS: A total of 209 patients met the criteria for entry into the study. Of these, 63.6% had LVH using Cornell criteria and 68.2% using LVH by Sokolow-Lyon criteria. Subsequently, ECHO confirmed the diagnosis in 2.9% using American Society of Echocardiography criteria and 1.5% using World Health Organization criteria. Thus the estimated prevalence of LVH in normotensive individuals was approximately 3%. CONCLUSION: The estimated prevalence of LVH in normotensive individuals appears to be relatively high if an ECG is the single investigation performed, which is common in our setting and may also be common in the developing world. However, using ECHO, the prevalence of LVH approaches a value similarly reported in the literature. Therefore, these findings raise two important issues: 1) the use of criteria such as the Cornell and Sokolow-Lyon voltage criteria established in the developed world from populations of vastly different ethnic backgrounds may not be widely applicable, and 2) all individuals suspected of having LVH should have an ECHO.

Epidemiology, risk analysis and clinical outcomes of acute myocardial infarction in Trinidad

Cardiovascular (CVS) disease is a global phenomenon and in Trinidad and Tobago, a small island developing country, remains the leading cause of death since the 1940's. It accounts for a proportional mortality of 25%.The main contributors are ischemic heart disease and stroke (1). Because CVS disease has global implications, the evaluation of the diverse outcomes of acute myocardial infarction (AMI) using population based hospital discharge databases is an important activity. The aim of this study is to describe the epidemiological features of acute myocardial infarction (AMI) and outcomes in patients admitted for tertiary care in Trinidad.

The rabies epidemic in Trinidad of 1923 to 1937: an evaluation with a Geographic Information System.

BACKGROUND: Rabies, although not preeminent among current infectious diseases, continues to afflict humans with as many as 55,000 deaths annually. The case fatality rate remains the highest among infectious diseases, and medical treatments have proven ineffective. OBJECTIVE: This study analyzes the rabies epidemic of 1929 to 1937 in Trinidad from a geographical perspective, using Geographic Information System (GIS) software as an analytical tool. SETTING: A small island developing country at a time when infectious diseases were rampant. METHODS: A review of the literature was undertaken, and data were collected on the occurrence of disease in both animal and humans populations and mapped using GIS software. Several factors identified in the literature were further explored such as land use/land cover, rainfall and magnetic declination. RESULTS: The bat rabies epidemic of 1923 to 1937 in Trinidad was migratory and seasonal, shifting to new locations along a definite path. The pattern of spread appears to be spatially linked to land use/land cover. The epidemic continues to present many unexplained peculiarities. CONCLUSION: Despite the fact that this epidemic occurred almost 7 decades ago, the application of new tools available for public health use can create new knowledge and understanding of events. We showed that the spatial of distribution of the disease followed a distinct pathway possible due to the use of electromagnetic capabilities of bats.

Gender differentials on breaking bad news: implications for communication skills training in medical school

Tactfully breaking news is an essential communication skill in the health professions. By the end of medical undergraduate training, the majority of students should be competent at breaking bad news in standardized patient examinations. Recent studies, however, suggest that this skill is not easily learned and there are notable differences in the strategies employed by males and females, even among practising professionals. These findings point to the possibility of gendered performance within medical school and raise questions about the efficacy of communication skills training. This chapter evaluates gendered achievement patterns and overall competence at breaking bad news on OSCE stations in years 2 and 5 for three cohorts of students at the School of Medicine, Faculty of Medical Sciences, University of the West Indies (UWI), St Augustine. Gender differentials were calculated for: (1) station scores, (2) item categories, and (3) item scores and evaluated on (1) statistical and practical significance, (2) variability, and (3) gendered impact. More than 25 percent of the students scored below the minimum level of competence for three of four years. However, there were few statistically or practically significant gender differentials on individual skills and process tasks. Nevertheless, by year 5, some females had a significant lead over males in the employment of socio-emotional/supportive strategies. It may be that the formal communication skills training (CST) programme, in the early years, did not lead to final-year mastery for some males. There is also the possibility that males and females prefer different strategies. There may be a need for contextualized training that allows both males and females to adopt a more patient-centred approach.

Contraceptive knowledge, attitudes and changing practices in women presenting to maternal and child health clinics in North Central Trinidad.

UNLABELLED: The relationship between contraceptive awareness and use in an environment of both high levels of unplanned pregnancies and prevalence of HIV/AIDS continues to be a major challenge. The objective of this study is to ascertain the knowledge of contraception and methods chosen in women of 18-45 years old attending primary care facilities in North Central Trinidad. METHODS: We used a cross-sectional study design with a knowledge, attitude, and practices type survey design. Five primary care facilities were selected using cluster sampling. All participants eligible for entry into the study were administered a structured, pretested questionnaire. RESULTS: 269 participants were enrolled in the study. The majority (88%) had good knowledge of contraceptive methods, yet this knowledge was not translated into the prevention of pregnancies as 64.3% had had an unplanned pregnancy. The male condom is now the predominant method of contraception. CONCLUSION: The study provides evidence on the level of knowledge of contraception methods and their use, as well as attitudes and practices among women who are pregnant or who recently completed a pregnancy. Although the knowledge of contraception methods was relatively high, attitudes and practice remain unacceptable and the male condom is now the predominant method of choice.

The epidemiology of unplanned pregnancies in North-Central Trinidad.

OBJECTIVE: to investigate the epidemiology of unplanned pregnancies in North-Central Trinidad and to evaluate the effect of level of education, marital status, religion, ethnicity, economics, and socioeconomic factors on the use of contraceptives in the society. METHOD: A cross-sectional study was conducted between April and May 2007 at four primary health care facilities in Trinidad using a de novo pilot-tested questionnaire. RESULTS: Of the 172 participants, 103 had unplanned pregnancies (64.0%). Of all unplanned pregnancies, 60.8% were due to lack of contraceptive use, 30% to failure of the contraceptives despite proper use, and 10% to misuse. The only notable association with unplanned pregnancies was having a prior unplanned pregnancy. CONCLUSION: The high prevalence of unplanned pregnancies was related to the effects of contraception, home ownership, and prior unplanned pregnancies.

Drugs in upper respiratory tract infections inpaediatric patients in North Trinidad / Medicamentos en infecciones del tracto respiratorio alto en pacientes pediátricos en Trinidad Norte

Objective: We explored the prescribing patterns of physicians in North Trinidad in treating upper respiratory tract infections (URTI) in paediatric patients and the appropriateness of drugs prescribed. Methods: A retrospective observational study was conducted, with a sample size of 523 paediatric patients, diagnosed with an URTI during the period of June 2003 to 22 June 2005. The study was conducted at five Primary Health Care Facilities in North Trinidad. Results: The three most frequent URTIs diagnosed were non-specific URTI, common cold, and acute tonsillitis in rank order. Four patterns of prescribing were identified, (1) no drug therapy [1.9%]; (2) antibiotic therapy alone [6.1%]; (3) antibiotic and symptomatic therapy [53.0%]; and (4) symptomatic therapy alone [39.0%]. The, most frequently prescribed antibiotics were penicillins (amoxicillin [46.3%] and amoxicillin/clavulanate [5.3%]) and a macrolide (erythromycin [6.1%]). The three symptomatic agents most frequently prescribed were paracetamol [40.1%]; diphenhydramine [29.1%]; and normal saline nasal drops [14.2%]. In 112 cases with swab analyses done, of these, 98.2% revealed a growth of commensals only, while 1.8% grew pathogenic micro-organisms. Of the cases showing commensal growth only, 84.6% were treated with an antibiotic, 14.5% were treated with symptomatic agents alone and 0.9% received no drug therapy at all. Conclusions: A large proportion of paediatric patients diagnosed with an URTI in North Trinidad was prescribed antibiotics although not indicated The inappropriate use of antibiotics can potentiate the worldwide trend of antimicrobial resistance (AU)

Objetivo: Exploramos los patrones de prescripción de los médicos en Trinidad Norte para el tratamiento de infecciones del tracto superior respiratorio (URTI) en pacientes pediátricos y la adecuación de los medicamentos prescritos. Métodos: Se realizó un estudio observacional retrospectivo, con un tamaño de muestra de 523 pacientes pediátricos diagnosticados con una URTI entre junio 2003 y 22 junio de 2005. Este estudio fue realizado en 5 centros de atención primaria en Trinidad Norte. Resultados: Las 3 URTI más frecuentemente diagnosticadas fueron, por orden, URTI no específicas, resfriado común, y amigdalitis aguda. Se identificaron 4 patrones de prescripción, (1) sin tratamiento farmacológico [1,9%]; (2) tratamiento antibiótico solo [6,1%]; (3) tratamiento antibiótico y sintomático [53,0%]; y (4) tratamiento sintomático solo [39,0%]. Los antibióticos más frecuentemente prescritos fueron penicilinas (amoxicilina [46,3%] y amoxicilina/clavulánico [5,3%]) y macrólido (eritromicina [6,1%)]. Los 3 agentes sintomáticos más frecuentemente prescritos fueron paracetamol [40,1%]; difenhidramina [29,1%]; y gotas de suero salino normal [14,2%]. En 112 casos con análisis de torundas, de los que el 98,2% reveló crecimiento de comensales, mientras que en el 1,8% crecieron microorganismos patógenos. De los casos que mostraron crecimiento de comensales sólo, se trataron con antibiótico el 84,6%, con agentes sintomáticos solos el 14,5% y el 0,9% no recibió tratamiento alguno. Conclusiones: A una gran proporción de pacientes pediátricos diagnosticados con una URTI en Trinidad Norte se le prescribió antibióticos aunque no estaban indicados. El uso inadecuado de antibióticos puede potenciar la tendencia mundial hacia las resistencias antimicrobianas (AU)

Trends in HIV/TB coinfection in Trinidad and Tobago for the period 1998-2007.

OBJECTIVES: The aim of this study was to extend the description of the epidemiologic pattern of human immunodeficiency virus (HIV)/tuberculosis (TB) coinfection from 1998 to 2007 in a high HIV/AIDS prevalence country. DESIGN AND METHODS: This study utilized registry data to determine yearly TB incidence and HIV coinfection. Mortality rates for coinfected patients were calculated and compared with patients receiving highly active antiretroviral therapy (HAART). RESULTS: From a TB population of 2010 registered patients, data was collected on the 466 patients with HIV/TB coinfection. The coinfection rate was found to be 23.6% for the study period. Patients on HAART were twice as likely to survive. DISCUSSION AND CONCLUSIONS: The incidence of TB and HIV/TB coinfection rates continues to be major challenges in the developing world. Demographic, socioeconomic trends as well as risk factors remain unchanged. Increased HIV screening and HAART coverage offers hope for the future.

Drugs in upper respiratory tract infections in paediatric patients in North Trinidad.

OBJECTIVE: We explored the prescribing patterns of physicians in North Trinidad in treating upper respiratory tract infections (URTI) in paediatric patients and the appropriateness of drugs prescribed. METHODS: A retrospective observational study was conducted, with a sample size of 523 paediatric patients, diagnosed with an URTI during the period of June 2003 to 22 June 2005. The study was conducted at five Primary Health Care Facilities in North Trinidad. RESULTS: The three most frequent URTIs diagnosed were non-specific URTI, common cold, and acute tonsillitis in rank order. Four patterns of prescribing were identified, (1) no drug therapy [1.9%]; (2) antibiotic therapy alone [6.1%]; (3) antibiotic and symptomatic therapy [53.0%]; and (4) symptomatic therapy alone [39.0%]. The, most frequently prescribed antibiotics were penicillins (amoxicillin [46.3%] and amoxicillin/clavulanate [5.3%]) and a macrolide (erythromycin [6.1%]). The three symptomatic agents most frequently prescribed were paracetamol [40.1%]; diphenhydramine [29.1%]; and normal saline nasal drops [14.2%]. In 112 cases with swab analyses done, of these, 98.2% revealed a growth of commensals only, while 1.8% grew pathogenic micro-organisms. Of the cases showing commensal growth only, 84.6% were treated with an antibiotic, 14.5% were treated with symptomatic agents alone and 0.9% received no drug therapy at all. CONCLUSIONS: A large proportion of paediatric patients diagnosed with an URTI in North Trinidad was prescribed antibiotics although not indicated The inappropriate use of antibiotics can potentiate the worldwide trend of antimicrobial resistance.

An evaluation of intervention strategies for HIV/AIDS in Trinidad and Tobago (2000-2007).

UNLABELLED: To evaluate the impact of health promotional strategies against The Acquired Immune Deficiency Syndrome (HIV/AIDS) in Trinidad and Tobago. METHODS: The HIV/AIDS Morbidity and Mortality reports were used to chart the pattern of change in the incidence of new HIV positive cases for the years 2000-2007 to determine the decrease in new HIV positive cases after 2004 with the implementation of the National Strategic Plan as well as What's Your Position (WYP), KNOW Your Status and Get Tested Now campaigns. These effects were tested using a quasi-experimental, post exposure design. A cross-sectional survey using street intercept interviews provided data on intervention effectiveness. Logistic regression analysis was used to determine the impact of HIV/AIDS campaigns, using their respective objectives. RESULTS: The study showed that a 16% decline in new HIV positive cases began during 2003 and 2004 and continued to decline by smaller margins until 2007. Data collected from the 599 participants with exposure to at least one campaign found that 92.7% reported awareness of WYP, followed by GTN (71.1%), RIU (42.6%), KYS (38.4%) and OUCH! (8.5%). 23.7% participants reported condom use post program exposure, whereas 19.0% practiced informed abstinence. A relationship was found between KYS and HIV/ AIDS Testing (p = .016) and between RIU and increased condom use (p = .010). CONCLUSIONS: Since the implementation of the programs, there have been positive lifestyle modifications among the sample population. Particularly "WYP" has been particularly effective in increasing awareness of practicing abstinence, faithfulness to one partner, condom usage when applicable, knowing their HIV status and further educating themselves about HIV/AIDS.

Has early initiation of sexual activity in adolescence had an impact on teenage childbearing in Trinidad and Tobago?

UNLABELLED: Published data indicate that young people are initiating sexual activity at an early age and many do not practice contraceptive methods, which should impact on adolescent fertility and births. OBJECTIVES: The aim of this study was to determine the impact of sexual activity at an early age on adolescent childbearing in Trinidad and Tobago. STUDY GROUP: Adolescents age 15-19 years. METHODS: All maternity records from public health care institutions (primary and tertiary) under the Ministry of Health caring for women in pregnancy were reviewed. Maternal age at the time of birth in addition to several other variables were recorded and several indices were constructed to determine trends in adolescent fertility and births. RESULTS: There was a steady decline in adolescent births especially from 1981 to 1990. reduced by approximately 50%. Adolescent fertility rates and the number of adolescents attending prenatal primary care clinics during the same period showed similar trends. CONCLUSIONS: Analysis of adolescent fertility rate would suggest that initiating sexual activity at an early age together with low utilization of contraceptive practices should lead to its increases over time. However we found that there was both a decline in fertility rates as well as adolescent births.