Interventions to prevent and control food-borne diseases associated with a reduction in traveler's diarrhea in tourists to Jamaica.

BACKGROUND: In 1996 a study found that approximately one in four tourists to Jamaica were affected with traveler's diarrhea (TD) during their stay. That year the Ministry of Health initiated a program for the prevention and control of TD. The aim of this ongoing program was to reduce attack rates of TD from 25% to 12% over a 5-year period by improving the environmental health and food safety standards of hotels. METHODS: Hotel-based surveillance procedures for TD were implemented in sentinel hotels in Negril and Montego Bay in 1996, Ocho Rios in 1997, and Kingston in 1999. A structured program provided training and technical assistance to nurses, food and beverage staff, and environmental sanitation personnel in the implementation of Hazard Analysis Critical Control Point principles for monitoring food safety standards. The impact of interventions on TD was assessed in a survey of tourists departing from the international airport in Montego Bay in 1997-1998 and from the international airport in Kingston in 1999-2000. The impact of the training and technical assistance program on food safety standards and practices was assessed in hotels in Ocho Rios as of 1998 and in Kingston from 1999. RESULTS: At the end of May 2002, TD incidence rates were 72% lower than in 1996, when the Ministry of Health initiated its program for the prevention and control of TD. Both hotel surveillance data and airport surveillance data suggest that the vast majority of travelers to Kingston and southern regions are not afflicted with TD during their stay. The training and technical assistance program improved compliance to food safety standards over time. CONCLUSION: Interventions to prevent and control TD in visitors to Jamaica are positively associated with a reduction in TD in the visitor population and improvements in food safety standards and practices in hotels.

Report of ezootic Angiostronglyus cantonesis from Jamaica [ABSTRACT]

OBJECTIVE: To study the status of infection with Angiostrongylus cantonensis in wild rats and snails in Jamaica following an outbreak of eosinophilic meningitis amongst tourists. METHODS: One hundred and thirty-one Rattus rattus and 94 R norvegicus were collected, mainly from the eastern portion of Jamaica. The animals were dissected and the heart and pulmonary arteries explored to reveal A cantonensis. Similarly, several species of land snails were collected. A portion of the head/foot was excised, fragmented and placed in separate dishes of digestion fluid (0.01 percent pepsin in 0.7 percent v/v aqeous HCI). Dishes were examined for nematode larvae 4-5 hours and 24 hours post-digestion. A microscopical comparison of larvae with museum specimens confirmed identification. RESULTS: Overall, significantly more R rattus (42.7 percent) than R morvegicus (21.3 percent) were infected (x2=11.28;p<0.0001). Considering only those parishes where 15 or more rats were collected (Hanover, Manchester, St.James, St. Elizabeth, Kingston and St.Andrew, and Portland) the prevalence of rodent infections ranged from 6 to 59 percent. Of three snails and one slug species collected, only Thelidomus asper harboured A cantonensis larvae. This snail was collected from Manchester where the highest prevalence of rodent infections also occurred. CONCLUSIONS: The findings indicate that A cantonensis is present in rats and snails in Jamaica. In the context of reports (1996, 2000) of eosinophilic meningitis on the island, we recommend that public health officials, clinical parasitologists and travel medicine practitioners consider A cantonensis as a causative agent of eosinophilic meningitis in residents and travellers to Jamaica. (AU)

Non-fatal violence-related injuries (VRIs) at the Kingston Regional Hospital (KRH): a preventable drain on resources [Abstract]

OBJECTIVE: We used data for a one-year period from the Violence-related Injury (VRI) Surveillance System at the Kingston Regional Hospital (KRH) in Jamaica to describe the patterns of non-fatal VRIs. We also carried out simulation analysis to estimate rates of hospital admission under various injury-reduction scenarios, and the potential savings that could be realized by reducing violent crimes and the hospital care associated with them. METHOD: Data used were for the one-year period, August 1, 1998 to July 31, 1999. In this period there were 6107 registered violence-related visits to the Accident and Emergency Department (AED) of the KRH, representing 11.5 percent of all recorded visits. Questions on the form included age, gender, circumstance and method of injury, victim-perpatrator relationship, and admission status. cases are non-fatal violence-related injuries resulting from threatened or actual use of physical force with the intent to cause harm, and do not include accidental or self-inflicted injuries. Simulation results are based on predicted values of admission status following maximum likelihood multiple regression models and the appropriate manipulation of relevant independent variables. RESULTS: 16.6 percent (1001) of subjects were admitted. The most common method of inflicting injury was by stabbing, accounting for 52.1 percent of injuries. Bodily force or blunt objects accounted for another 37.9 percent, while gunshot wounds accounted 7.3 percent of injuries. Multivariate analyses indicated gumshot injuries, stab injuries, being male, between the ages of 15 and 44 years, receiving the injury in November or December, and being injured by a stranger or unknown assailant, to be significant correlates of probability of admission ranging from 12 percent to 44 percent, with estimated savings of up to 20 percent of the annual budget of KRH. CONCLUSIONS: Non-fatal VRIs compromise a significant proportion of admissions to KRH. There are predicatble correlates of the likelihood of admission, and educational drives aimed at reducing specific risk factors can lead to large savings of limited resources. (AU)

Factors influencing inpatient mortality of medical patients

OBJECTIVE: To investigate factors influencing inpatient mortality and length of stay among medical patients at a public hospital. METHODS: A case-control study involving a 10 percent sample of medical admissions who died (n=109) was done at the Kingston Regional Hospital during 1998. These were matched for age, gender and admission date to 2 controls (n=180) where death did not occur. Trained personnel abstracted information from personnel records. RESULTS: The sample comprised 147 men and 139 women of mean/Standard Deviation (SD) age 61.3ñ18.1 years and range of 12 to 94 years. The mean/SD length of stay was 6.3ñ6.0 days with a median of 5 days. Length of stay did not differ by gender (p=0.69) or mortality (p=0.86). Re-admission accounted for 34.3 percent of admissions occuring at a median of 174 days. There was 70 percent agreement between the provisional diagnosis at admission and the primary discharge diagnosis. The commonest primary diagnoses were diabetes mellitus and hypertension (14 percent each). Stroke, pneumonia and cancer each accounted for over 5 percent of primary diagnoses. Risk of death was greater in women who were alone (single or widowed/divorced/separated) than in those in a union - odds ratio (OR) and 95 percent confidence interval (95 percent CI) 3.63 (1.36, 9.67). In men the OR (95 percent CI) was 0.94 (0.38-2.31). Cancer, stroke chronic renal failure and pneumonia were associated with an increased risk of in-hospital mortality and so was documentation of examination by a consultant. There was an inverse association between the number of entries per day in patients' notes and the risk of death. Less than 2 percent of admissions had a record of patient satisfaction. Nurses notes were judged to be adequate in 76.5 percent of admissions but only 19.2 percent of patient records were rated as good overall. Good quality records were not associated with better survival or shorter hospitalization. CONCLUSION: The relationship between process of care and inpatient mortality is complex and clear associations were not demonstrated for overall mortality. Cause-specific mortality may be a more informative outcome for quality of care studies. (AU)

Maternal and neonatal factors associated with poor cognitive outcomes at 11 years of age in a cohort of low birth weight infants in Jamaica

OBJECTIVE: To determine maternal and birth factors that are associated with poor cognitive outcome in a low-birth weight (LBW) cohort enrolled at birth and examined at 11 years of age. The identification of these factors will help to plan intervention strategies to improve cognitive outcomes in LBW infants. DESIGN AND METHODS: In September and October 1986, all Jamaican-born children were enrolled in the Jamaican Perinatal Mortality Survey. At that time, a Main Questionnaire, asking questions about maternal demographic, social, and medical conditions and reviewing aspects of the pregnancy, labour, and delivery, was administered. A geographical subset of children was examined for cognitive abilities at 11 years of age using the Peabody Picture Vocabulary Test and Ravens Progressive Matrices. Former LBW children were included in the testing even though they were outside of the geographical area. Of the 1569 children tested, 107 were former LBW infants. Linear regressiong models were developed associating variables from the Main Quesitionnaire with outcomes on the cognitive tests. Based on the regression models, a Nursery Checklist was developed that could be used to identify children for referral to early intervention programmes. RESULTS: Twenty-one (20 percent) of the 107 ex-LBW children performed two standard deviations below the mean of the entire cohort. Maternal and birth factors associated with poor outcome were: living in poor housing conditions, not taking prenatal iron, not working outside the home and the infant not crying at birth. The Nursery Checklist identified 90 percent of the infants with poor cognitive outcomes while only referring 56 percent of the LBW population to intervention services. CONCLUSION: The factors associated with poor cognitive outcome include two socio-economic factors, an indication of infant viability at birth, and a possible nutritional deficiency. These factors can be used to institute primary interventions to ameliorate these conditions and to identify children in need of secondary interventions in early childhood.(Au)

Maternal lifestyle and pregnancy outcome in Jamaica: the effects of cigarette and marijuana smoking, alcohol use and sexual activity

Cigarette smoking, marijuana and alcohol use, and coital activity have been investigated for effect on foetal birth weight and gestation chiefly in developed countries. Apart from the relationship between cigarette smoking and heavy alcohol intake and growth retardation, the evidence for poor birth outcome is controversial. Little is known of the effect of these lifestyle factors in developing countries where poor pregnancy outcome is common. Using data from a population based perinatal study in Jamaica, the effect of lifestyle factors was ivestigated in 8486 babies. Data collected by midwives at birth included the date of the last menstrual period, socio-demographic characteristics and frequency of tobacco, marijuana and alcohol use during pregnancy, as well as coital frequency at quickening and at delivery. Babies were weighed and measured. Live birth outcomes investigated were low birth weight, preterm birth and growth retardation, with population rates of 10.1 percent, 8.7 percent and 9.7 percent, respectively. Data were processed using SPSS and BMDP statistical packages. The prevalence of cigarette, marijuana and alcohol use was 7.0 percent, 2.1 percent and 16.4 percent respectively. 74 percent and 27 percent of women were having sexual intercourse at quickening and in the week prior to delivery, respectively. Apart from coital frequency at quickening, life style factors were strongly associated with each other. All life style factors were associated with social class. On univate analysis, significant associations were found between cigarette smoking and low birth weight (p,0.04) and growth retardation ,0.05). Association between marijuana use and low birth weight and between alcohol use and lower incidence of preterm birth failed to reach significance (p=0.05, p=0.16). When stratified by frequency of use, there was a significant trend in both cases (p<0.05, p<0.04). After controlling for socio-demographic characteristics and other life style factors, associations were maintained between cigarette smoking and low birth weight. Foetal effects of maternal cigarette smoking are present even in al low prevalence country. The effect of marijuana use is less conclusive, but the data suggest that this activity may be detrimental to the foetus. (Au)

Hotel based surveillance of health conditions amongst travellers to Jamaica

Pursuant of the goal to implement a strategy for prevention and control of travellers' diarrhoea (TD), a programme for the surveillance of selected health conditions amongst visitors and staff was pilot tested in 5 resort hotels in Jamaica. Surveillance reports submitted on a weekly basis by the hotel nurses were analyzed for usage of hotel medical facilities; cases due to accidents, diarrhoea and associated symptoms; and acute respiratory tract infections (ARIs). Diarrhoea visits accounted for the lowest number of visits to the nurses' station of all properties, ARIs for the highest. Highest frequency of diarrhoea visits occurred in hotels 4 and 5 being 9.3 and 7.3 percent of all visits to the nurses' station. 70 percent of guest TD cases and 26 percent of staff reported with more than 6 evacuations per day. Abdominal cramps was the most frequent complaint, being present in 38 percent and 43 percent of staff. Vomiting was an associated symptom in 17.6 percent of guest cases and in 26.4 percent of staff cases. A hotel 1, fever was an associated symptom in 23.6 percent and blood in stool in 4.9 percent of guest cases. At hotel 4, fever was present in 14.1 percent and blood in stool of 1.5 percent of guest cases. Amongst staff at hotels 1 and 4, 22.2 percent and 3.8 respectively, and fever. Blood in stool was infrequent amongst staff. These data confirm the usefulness of the surveillance tool for the analysis of TD in hotels.(AU)

The aetiology of diarrhoea in five hotels in Jamaica

Diarrhoea is a self-limited disease which commonly affects tourists traveling from low risk to high risk destinations. It is estimated to affect 20-50 percent of the residents of industrialized countries who visit a developing country each year. Jamaica and other countries of the Caribbean, Latin America, Sub-Saharan African and South East Asia are considered to be intermediate to high risk tourist destinations. Data generated between 1979 and 1981 estimated that approximately 20 percent of European visitors to the Caribbean are afflicted with travellers' diarrhoea (TD) during their stay. Since the time, tourist arrivals to Jamaica have increased from 0.4 to 1.2 millions. To meet the challenges faced by this rapid growth, significant changes have been made to the tourism product, which may have impacted on the health visitors. Immediately following Jamaica's citation by the US Travel Advisory after an outbreak of typhoid in the parish of Westmoreland in 1991, the country was faced by a threat of a cholera epidemic in neighbouring Latin America. With a view to implementing a strategy for cholera prevention and control of cholera and other foodborne diseases, the Ministry of Health initiated a study of epidemiology and aetiology of TD in Jamaica. The first phase of the study was designed to assess the magnitude of TD amongst travellers to Jamaica, by region and by hotel. Those data have been reported elsewhere. Bacterial enteropathogens cause 80 percent of TD.(AU)

International variation in the incidence of hypertension in pregnancy among primiparae: the Jamaican experience - abstract

The study was undertaken to determine the natural history of blood pressure measurements during pregnancy in a geographical population of primiparae in the Caribbean, and to compare this with similarly measured populations. It used data collected during a randomized controlled trial of low dose aspirin. Serial measurements of blood pressure, proteinuria and maternal weight were obtained at each antentalepisode and inpatient admission. The population comprised 6043 primiprae resident in the parishes of Kingston and St. Andrew, Jamaica, with singleton pregnancies and no indications for exculsion from randomization in the low dose aspirin trial. The mean systolic and diastolic blood pressure at 20 - 24 weeks gestation (105mm Hg and 63mm, respectively) was substantially lower than that found in four different population in south-east Asia or in the United Kingdom (UK). During the latter half of pregnancy, there was a rise of 4 mm Hg systolic and 5 mm Hg diastolic, substantially less than that found among primiparae in China (9mm) or the UK (9mm). There were, however, high prevalences of eclampsia and proteinuria, and maternal and perinatal mortality ascribed to maternal hypertension is substantial. Proteinuria prevalence started to increase with diastoblic blood pressures of 80 mm. In conclusion, there is evidence that definition of hypertension in pregnancy in Jamaica should involve lower levels of diastoblic blood pressure than those used in many countries. No epidemiological studies are yet available to ascertain difference between European countries or American populations. These should help formulate coherent theories as to the aetiology of the hypertensive disorders of pregnancy(AU)

Low dose aspirin in pregnancy are there any benefits

Although the question of major prophylactic benefits of low-dose aspirin in preventing pre-eclampsia or intrauterine growth retardation in pregnancies of mothers who had had such a history has been convincingly negated by the CLASP study, there has remained a question whether pregnancies of primiparae (the group most at risk of such outcomes) might benefit. This study was designed as a randomized controlled trial to address this possibility and other hypotheses arising from the CLASP study. The hypotheses addressed concerns whether low-dose aspirin prevented in or delayed the onset of the hypertensive disorders of pregnancy, including pre-eclampsia, and eclampsia, and whether preterm delivery or low birthweight rates were reduced. In addition, the study was designed to assess whether enrolment, early rather than late, had the most beneficial effect. In parallel, possible adverse effects on mother and infant were monitored. A total of 6275 primiparae were enrolled from 12 weeks gestation in community clinics in Kingston and St. Andrew in Jamaica; 97 percent of them were followed throughout pregnancy. There were no differences in the development of markers of hypertensive disorders, the prevalence of pre-eclampsia or eclampsia except for oedema, which was more prevalent in those on placebo. Mothers on the drug showed no differences in mean diastolic bloodpressure at any stage of pregnancy - they were not less likely to deliver preterm or have a larger foetus. They were, however, significantly more likely to suffer from bleeding disorders antenatally, intrapartum and postpartum. It is concluded that low-dose aspirin has no place in the management of normal pregnancy (AU)

Registration of births, stillbirths and infant deaths in Jamaica

BACKGROUND: Vital statistics underestimate the prevalence of perinatal and infant deaths. This is particularly significant when these parameters affect eligibility for international assistance for newly merging nations. OBJECTIVE: To determine the level of registration of livebirths, stillbirths and infant deaths in Jamaica. METHODOLOGY: Births, stillbirths and neonatal deaths identified during a cross-sectional study (1986): and infant death identified in six parishes (1993) were matched to vital registration documents filed with the Registrar General. RESULTS: While 94 percent of livebirths were registered by one year of age (1986), only 13 percent of stillbirths (1986) and 25 percent of infant deaths (1993) were registered. Post neonatal deaths were more likely to be registered than early neonatal deaths. Frequently the birth was not registered when the infant died. Birth registration rates were highest in parishes with high rates of hospital deliveries (rs=0.97, P<0.001) where institutions notify the registrar of each birth. Hospital deaths, however, were less likely to be registered than community deaths as registrars are not automatically notified of these deaths. CONCLUSIONS: To improve vital registration, institutions should become registration centres for all vital events occurring there (births, stillbirths, deaths). Recommendations aimed at modernizing the vital registration system in Jamaica and other developing countries are also made(AU)

Factors determining admission to neonatal units in developing countries - abstract

To identify those factors associated with admission to neonatal care units in a developing country, 1823 newborns admitted to Jamaica's eight neonatal care units over a six-month period were compared to 9563 non-admitted newborns identified during an islandwide cohort study. Maternal sociodemographic characteristics, past obstetric history, infant's growth parameters, and mode and place of delivery were investigated. Babies of mothers resident in the two regions of the island where specialist paediatric services were available had increased odds for admission (O.R. = 1.45, 1.22) compared to those living elsewhere (O.R. = 0.70, 0.80). Maternal history of a previous stillbirth or late neonatal death was not. Very low birthweight infants of gestational age 28 - 31 weeks were more likely to be admitted than those under 28 weeks with odds of 1.45 and 0.34, respectively. Factors determining neonatal admission in the developing world may be quite different from those of developed countries (AU)

Under-users of antenatal care: a comparison of non-attenders and late attenders for antenatal care, with early attenders

Demographic, behavioural, environmental, economic and obstetric history data from the Jamaican Perinatal Morbidity and Mortality Survey were examined to identify characteristics of women who do not attend for antenatal care, or present late instead of early for care, using multiple logistic regression. Non-attenders were more likley to be teenagers, unmarried, in unions of very short duration, smokers and women who felt that friends and relatives were not supportive. Multigravid non-attenders often had short inter-pregnancy intervals and included women who had experienced a post neonatal death. They were often drawn from deprived environments (lack of sanitation, water supplies). Late attenders shared features common to non-attenders (teenagers, unmarried, multigravid). Many however were self employed and did not fit the depressed profile of the non-attender. Most multigravidae who attended late had had previously uneventful pregnancies, including this one. Early attenders had little in common with not-attenders and late attenders. They were older, many had a secondary or tertiary education, were married and were generally middle class women. The group however included high risk multigravidae who had previous pregnancy complications or bad outcomes. Programmes aimed at reaching non-attenders must focus on the wider social and economic needs of these women and must give them a sense of their own power to effect change in their lives. Reaching the late attender will be more difficult and may be unnecessary with the possible exception of the teenager. She needs to be treated in a more sympathetic and non-judgmental way as this is often a high risk pregnancy. More fundamental changes require improved educational and employment opportunities for women as the best consumer is an educated consumer (AU)

Maternal height and live birth outcome in a developing country - abstract

This study aimed to determine the association between maternal height and pregnanacy outcome in a developing country. Data collected during the 1986-87 islandwide Jamaica Perinatal Survey were analysed. During this survey, all mothers were interviewed at delivery and their heights measured and their babies were weighed and examined. Only the mothers who had live births with a recorded birth weight and gestational age were included in this study. This was necessary to categorize infants as low birth weight, growth retarded or preterm birth. The live birth outcomes are under investigation. Women who were less than 150 cm in height were at highest risk for all poor live birth outcomes, but women who were between 150 and 162 cm were also at significantly increased risk of poor live birth outcomes, when compared to women with a height of at least 165 cm. The odds ratios for delivery of a baby with low birth weight, growth retardation or pre-term birth were 2.8, 2.9 and 1.7 times greater, respectively, for shorter women (<150 cm) than for taller women (>165 cm). These were independent of socioeconomic factors. Maternal height represents a cheap, easy and accurate tool that can be used to describe women with a high risk of poor birth outcome (AU)

Transient hypertension in pregnancy is not pre-eclampsia: - abstract

Data from the Jamaican Perinatal Survey were examined to compare the management of women with pre-eclampsia and transient hypertension in pregnancy. The findings indicate that women with transient hypertension experienced no greater risk of perinatal mortality or growth retardation than the general population of women in spite of being managed more conservatively than their counterparts with pre-eclampsia. It would appear that interventions such as induction or Caesarean delivery are not generally warranted in the management of these cases as the complication does not carry the same risks to the infant or the mother that pre-eclampsia does. Further research is needed to determine what proportion of Jamaican women who present with an initial rise in blood pressure go on to develop pre-eclampsia and whether other signs of the pre-eclampsia syndrome would provide more sensitive indicators of risk than blood pressure, given a high prevalence of complications at lower blood pressures among Jamaican women and the low predictive value of blood pressure in identifying women at risk of eclampsia. Outpatient instead of inpatient management of women with transient hypertension appears to be a potentially cost-effective approach to care of these lower-risk women (AU)

Congenital syphilis: why has prevention failed? - abstract

The incidence of congenital syphilis reflects the incidence of total and maternal syphilis in the community and syphilitic seroprevalence rates among antenatal attenders. We reviewed notifications of syphilis in Jamaica over the last 20 years as well as 30 cases of congenital syphilis admitted to Bustamante Hospital Children and the University Hospital of the West Indies during 1986 and 1987. Reported syphilis cases were 2611 in 1972, fell to 1367 in 1979, rose to 3070 in 1989 and again declined to 2121 in 1992. Between 1979 and 1985 there were 10 or less reported cases of congenital syphilis annually. Increasing numbers of congenital syphilis were reported in the late 1980s with a high of 60 cases in 1990 which has since fallen to 50 cases in 1992. The antenatal clinic VDRL reactor rate increased from around 7 percent in 1980 to 17 percent in 1990. The increase in congenital syphilis appears to be related to the increase in syphilis throughout the Americas, the decline in the public health services due to economic constraints, the shortage of nurses and laboratory staff and a breakdown in antenatal care, specifically the prompt identification and treatment of pregnant women with syphilis. Measures are being put in place to address these deficiencies and prevent the occurrence of congenital syphilis in Jamaica (AU)

A simple method of assessing quality of antenatal care - abstract

Guidelines established by the Ministry of Health for delivery of primary level antenatal care were used as a standard for evaluating the quality of antenatal care provided to cohort study mothers interviewed by the Jamaican Perinatal Morbidity and Mortality Survey. Services assessed included surveillance for pre-eclampsia (blood pressure, urine test, weight gain), screening for anaemia and syphilis, blood group identification, tetanus toxoid immunization, iron supplementation and health education (family planning, breast feeding). Provision of these services was summarized into a quality-of-care score. Mothers who received 3 or fewer of these services were considered to have had poor quality care, 4-7, average, and 8-10, good care. Non-attenders were included among those with poor care. Multiple logistic perinatal mortality and quality of care, controlling for service-related factors and social and biological predictors of perinatal death. Good quality antenatal care, as defined, contributed to reducing the risk of perinatal death after controlling for known risks. Compared to women with good care, those with average care were twice as likely, and those with poor quality care four times more likely, to experience a perinatal death. Careful attention to the basic elements of care increases the likelihood that problems will be identified. With appropriate referral for attention, improved perinatal outcome can be expected. Reducing the perinatal mortality rate can be as simple as adhering to established guidelines (AU)