The impact of COVID-19 on heart failure admissions in Suriname-A call for action.

INTRODUCTION: During the height of the COVID-19 pandemic, there was a worldwide reorganization of healthcare systems focusing on limiting the spread of the virus. The impact of these measures on heart failure (HF) admissions is scarcely reported in Low and Middle Income Countries (LMICs) including Suriname. We therefore assessed HF hospitalizations before and during the pandemic and call for action to improve healthcare access in Suriname through the development and implementation of telehealth strategies. METHODS: Retrospectively collected clinical (# hospitalizations per patient, in hospital mortality, comorbidities) and demographic (sex, age, ethnicity) data of people hospitalized with a primary or secondary HF discharge ICD10 code in the Academic Hospital Paramaribo (AZP) from February to December 2019 (pre-pandemic) and February to December 2020 (during the pandemic) were used for analysis. Data are presented as frequencies with corresponding percentages. T-tests were used to analyze continuous variables and the two-sample test for proportions for categorical variables. RESULTS: There was an overall slight decrease of 9.1% HF admissions (N pre-pandemic:417 vs N during the pandemic: 383). Significantly less patients (18.3%, p-value<0.00) were hospitalized during the pandemic (N: 249 (65.0%)) compared to pre-pandemic (N: 348 (83.3%)), while readmissions increased statistically significantly for both readmissions within 90 days (75 (19.6%) vs 55 (13.2%), p-value = 0.01) and readmissions within 365 days (122 (31.9%) vs 70 (16.7%), p-value = 0.00) in 2020 compared to 2019. Patients admitted during the pandemic also had significantly more of the following comorbidities: hypertension (46.2% vs 30.6%, p-value = 0.00), diabetes (31.9% vs 24.9%, p-value = 0.03) anemia (12.8% vs 3.1%, p-value = 0.00), and atrial fibrillation (22.7% vs 15.1%, p-value = 0.00). CONCLUSION: HF admissions were reduced during the pandemic while HF readmissions increased compared to the pre-pandemic period. Due to in-person consultation restrictions, the HF clinic was inactive during the pandemic period. Distance monitoring of HF patients via telehealth tools could help in reducing these adverse effects. This call for action identifies key elements (digital and health literacy, telehealth legislation, integration of telehealth tools within the current healthcare sector) needed for the successful development and implementation of these tools in LMICs.

Hurricane Michael and Adverse Social and Mental Health Risk Factors.

OBJECTIVES: To assess changes in mental health and social risk factors in pregnant women in counties affected by Hurricane Michael (October 2018). METHODS: Data from the Universal Perinatal Risk Screen (UPRS) and vital statistics for the state of Florida were obtained. Prenatal risk factors (unplanned pregnancy, mental health services, high stress, use of tobacco or alcohol, young children at home or with special needs, trouble paying bills) were compared in the year before and year after Hurricane Michael in affected counties (n = 18,887). Log-Poisson regression with robust variance was used for binary outcomes, adjusting for maternal age, race, BMI, and education. RESULTS: A smaller proportion of pregnant women were screened in the months after the hurricane. No changes were seen in overall scores. The proportion referred was lower in the 1 month after Michael compared to that in 1 month before Michael (RR 0.78, 95% CI = 0.71, 0.86), but greater in the year after (RR = 1.07, 95% CI: 1.04, 1.10). Most individual risk factors on the screener did not change significantly, except having an illness that required ongoing medical care was less common in the short term (3 months after vs. 3 months before: aRR = 0.76, 95% CI: 0.66, 0.87), and more common in the longer term (1 year after vs. 1 year before, aRR = 1.09, 95% CI: 1.02, 1.18). Birth certificate data suggested smoking during pregnancy was higher among women who experienced Michael during their pregnancies (aRR = 1.15, 95% CI: 1.01, 1.32). DISCUSSION: Perinatal screening and referral declined in the short-term aftermath of Hurricane Michael.

Validity, reliability, and transcultural adaptations of the Bayley Scales of Infant and Toddler Development (BSID-III-NL) for children in Suriname.

BACKGROUND: A valid and reliable measure of infant neurodevelopment is needed in Suriname, South America. The Bayley Scales of Infant and Toddler Development, 3rd edition (BSID-III), was created for evaluation of United States infants and toddlers and subsequently validated for use in Dutch speaking infants of the Netherlands (BSID-III-NL). Given that Suriname was a previous Dutch colony and Dutch remains the national language of Suriname, this study sought to evaluate the psychometric properties of the BSID-III-NL in Suriname. AIMS: Given that the cultural context differs between Suriname, the United States, and the Netherlands, the aims of this study were to determine if any cultural adaptations of the BSID-III-NL were needed for Surinamese infants and to evaluate its psychometric properties. METHODS: Two hundred and ninety-nine infants between the ages of 10 to 26 months were assessed in three geographic regions of Suriname between May 2018 and July 2019. Minor adaptations to the BSID-III-NL imagery were made based on the input of Surinamese pediatricians and neuropsychologists who were also involved in the administration of the BSID-III-NL in Suriname. Raw scores were collected for the cognitive, communicative, and motor subscales of the BSID-III-NL. Factor structure was evaluated with exploratory factor analysis and cluster analysis, and reliability of internal consistency was assessed using Cronbach's alpha coefficient for each subscale. RESULTS: Content validity was endorsed by pediatricians and neuropsychologists in Suriname who participated in the administration of the BSID-III-NL. Construct validity was demonstrated through agreement of items from cluster analysis where at least 81.56% of all variability was explained by clustering with correct or incorrect responses and mean raw scores in subscales increased with age group. Cronbach's alpha coefficient was above 0.77 for all subscales. CONCLUSIONS: This internationally validated developmental measure was found to be valid and reliable in assessing neurodevelopment of infants in Suriname.

Adequate antenatal care and ethnicity affect preterm birth in pregnant women living in the tropical rainforest of Suriname.

BACKGROUND: Adequate antenatal care (ANC) services are key for early identification of pregnancy related risk factors and maintaining women's health during pregnancy. This study aimed to assess the influence of ANC provided by the Medical Mission Primary Health Care Suriname (MMPHCS) and of ethnicity on adverse birth outcomes in Tribal and Indigenous women living in Suriname's remote tropical rainforest interior. METHOD: From April 2017 to December 2018 eligible Tribal and Indigenous women with a singleton pregnancy that received ANC from MMPHCS were included in the study. Data on low birth weight (LBW < 2500 g), preterm birth (PTB < 37 weeks), low Apgar score (< 7 at 5 min), parity (≤1 vs. > 1) and antenatal visits utilization (≥8 vs. < 8) in 15 interior communities were retrospectively analyzed using descriptive statistics, crosstabs and Fisher's exact tests. RESULTS: A total of 204 women were included, 100 (49%) were Tribal, mean age was 26 ± 7.2 years and 126 women (62%) had 8 or more ANC visits. One participant had a miscarriage; 22% had adverse birth outcomes: 16 (7.9%) LBW and 30 (14.8%) PTB; 7 women had a child with both PTB and LBW; 5 women had stillbirths. None of the newborns had low Apgar scores. Maternal age, ethnicity, ANC and parity were associated with PTB (χ2 = 8,75, p = 0.003, χ2 = 4,97, p = 0.025, χ2 = 17,45, p < 0.001, χ2 = 11,93, p < 0.001 respectively). CONCLUSION: Despite an almost 100% study adherence over one fifth of women that received ANC in the interior of Suriname had adverse birth outcomes, in particular PTB and LBW. Younger nulliparous Indigenous women with less than the recommended 8 ANC visits had a higher risk for PTB. The rate of adverse birth outcomes highlights the need for further research to better assess factors influencing perinatal outcomes and to put strategies in place to improve perinatal outcomes. Exposure assessment of this sub-cohort and neurodevelopment testing of their children is ongoing and will further inform on potential adverse health effects associated with environmental exposures including heavy metals such as mercury and lead.

Presence of pesticide residues on produce cultivated in Suriname.

Agricultural pesticides are widely used in Suriname, an upper middle-income Caribbean country located in South America. Suriname imported 1.8 million kg of agricultural pesticides in 2015. So far, however, national monitoring of pesticides in crops is absent. Reports from the Netherlands on imported Surinamese produce from 2010 to 2015 consistently showed that samples exceeded plant-specific pesticide maximum residue limits (MRLs) of the European Union (EU). Consumption of produce containing unsafe levels of pesticide residues can cause neurological disorders, and particularly, pregnant women and children may be vulnerable. This pilot study assessed the presence of pesticide residues in commonly consumed produce items cultivated in Suriname. Thirty-two insecticides (organophosphates, organochlorines, carbamates, and pyrethroids) and 12 fungicides were evaluated for their levels in nine types of produce. Pesticide residue levels exceeding MRLs in this study regarded cypermethrin (0.32 µg/g) in tomatoes (USA MRL 0.20 µg/g), lambda-cyhalothrin (1.08 µg/g) in Chinese cabbage (USA MRL 0.40 µg/g), endosulfan (0.07 µg/g) in tannia (EU MRL 0.05 µg/g), and lindane (0.02 and 0.03 µg/g, respectively) in tannia (EU MRL 0.01 µg/g). While only a few pesticide residues were detected in this small pilot study, these residues included two widely banned pesticides (endosulfan and lindane). There is a need to address environmental policy gaps. A more comprehensive sampling and analysis of produce from Suriname is warranted to better understand the scope of the problem. Preliminary assessments, using intake rate, hazard quotient, and level of concern showed that it is unlikely that daily consumption of tannia leads to adverse health effects.

Mercury pollution in Suriname – A threat to family health

OBJECTIVE: To examine the magnitude of mercury pollution of the aquatic environment in Suriname, to demonstrate that most mercury contamination originates from small-scale gold mining and to show the adverse health effects of mercury exposure in human population of the interior. SUBJECTS AND METHODS: In geographically dispersed locations across Suriname, bottom sediment and fish were analysed for mercury. To demonstrate the anthropogenic source of the mercury, core samples in flood plains were analysed to determine the pattern of mercury levels with depth. Mercury exposure was documented in five village communities through dietary surveys and hair analysis. RESULTS: Both bottom sediments and predatory fish were often above international norms in most areas of Suriname, including outside the mining area. All samples taken at marine mud flats were low in mercury. Core samples from coastal flood plains showed decreasing levels of mercury with depth. Mercury levels in the human population were elevated, but on average below the US Environmental Protection Agency Benchmark Dose. The highest levels occurred in a village upstream of any gold mining, isolated from access to other parts of the country. CONCLUSIONS: Most of Suriname is polluted with mercury, directly resulting from unsafe small-scale gold mining practices, or indirectly through water or wind deposition. The pattern of mercury in core samples demonstrates the anthropogenic source of the mercury. Villagers in the interior of Suriname show elevated levels of mercury, levels depending on the amount of local fish consumed and therefore on the degree of isolation of the village.

Spatial Distribution of Epidemiological Cases of Dengue Fever in Suriname, 2001-2012.

OBJECTIVE: To characterize the frequency, incidence and severity of dengue fever in Suriname and to detect historic clusters of disease by integrating epidemiological data into a spatial visualization platform. METHODS: The frequency, incidence and severity of all reported dengue fever (DF) and dengue haemorrhagic fever (DHF) cases in Suriname from 2001 to 2012 were calculated and stratified by demographic factors. Using a geographic information systems (GIS) platform, we visualized the distribution of DF cases and used Moran's I to detect autocorrelation. Furthermore, a retrospective spatial Poisson probability model was used to identify local clusters of DF within Suriname. Local clusters were divided into neighborhoods and individual DF cases were mapped to the street level. RESULTS: In Suriname, cases of DF emerge in cyclical patterns (three to five years) with seasonal peaks following the short and the long rainy season. Chi-square analysis indicated a statistically significant (p < 0.05) difference between age group, ethnicity and district and the onset of DHF. The spatial analysis detected spatial autocorrelation and four statistically significant (p < 0.05) clusters were identified in the two most populated districts of Paramaribo and Wanica. CONCLUSION: In Suriname, identification of demographic and environmental risk factors that contribute to the development of DHF is essential to determine how preventive action can be more effectively allocated. The integration of epidemiological data into a GIS platform allowed for the identification of historic epidemiological clusters of dengue which will be used to guide environmental health studies in Suriname.

Mobile health technology-enabled community health workers as pesticide interventionists in rural Suriname

OBJECTIVE: To bolster access for vulnerable communities to urgent pesticide-related health information and services using a mobile health technology-enabled community health worker (CHW) strategy. DESIGN AND METHODS: The project was designed to demonstrate the effectiveness of mobile health technology–enabled CHWs in promoting safe pesticide use in pesticide-induced suicide-prone communities in Suriname. The team focused on three interconnected components: message mapping, validation, and delivery testing. The text messages were tested to assess content, literacy, and the ability to solicit a recipient response to determine the effectiveness of mobile technology as a health intervention tool. RESULTS: Thirty-nine text messages addressed the following key themes: pesticide miss/overuse, pesticide accessibility contributing to its use as an attempted or successful suicide strategy, and pesticide handling and disposal. For each of these themes, at least three messages were developed. Most text messages emphasized safe pesticide handling as the root cause of both misuse and access. (The pesticide awareness and education campaign will be expanded country-wide.) CONCLUSION: The mobile health technology- enabled CHWs functioning as pesticide interventionists demonstrated that bidirectional text messaging was a promising awareness and education intervention strategy. Focusing on safe handling was a reasonable target for intervention in the absence of a comprehensive national pesticide policy governing import, distribution, access, handling, and disposal. Of note is that none of the messages to date directly focused on suicide, confirming the strategy to address suicide prevention as a holistic public health issue under a safe pesticide use “umbrella” rather than as an isolated, stigma-provoking problem.

An evaluation of pesticide residue levels in selected produce and a medical plant in Suriname

OBJECTIVE: This specific study objective was to characterize pesticide contamination in produce and medicinal plants in Suriname. DESIGN AND METHODS: Samples were collected during different seasons from several markets in Suriname. The preliminary assessment collected 8 products from the largest market in Paramaribo during the rainy season. Results from the preliminary assessment informed the selection of products for the expanded assessment, which was focused on 7 products sampled from the same market, as well as the largest market in district Wanica during the dry season. Additionally, the vegetable Tannia was sampled at 3 other markets within Paramaribo. All samples were analyzed for pesticide residue with Gas Chromatography Electron Capture Detector. RESULTS: The preliminary assessment conveyed that 12.5% of the samples tested had pesticide residues. The expanded characterization showed that 35.3% of the samples tested positive for pesticide residues. Half of all the samples with pesticide residues exceeded either 1 or more Maximum Residual Levels (MRL) in the expanded assessment. Among the identified residues were Endosulfan and Lindane, which are banned for use in Suriname and are globally being phased out under the Stockholm Convention. CONCLUSIONS: A percentage of selected produce items cultivated in Suriname were contaminated with pesticides. To ascertain the association with adverse health effects, this research will be followed up by a human health assessment that includes a dietary assessment and biomarker testing.

Few Associations Found between Mold and Other Allergen Concentrations in the Home versus Skin Sensitivity from Children with Asthma after Hurricane Katrina in the Head-Off Environmental Asthma in Louisiana Study.

Mold and other allergen exposures exacerbate asthma symptoms in sensitized individuals. We evaluated allergen concentrations, skin test sensitivities, and asthma morbidity for 182 children, aged 4-12 years, with moderate to severe asthma, enrolled 18 months after Katrina, from the city of New Orleans and the surrounding parishes that were impacted by the storm, into the Head-off Environmental Asthma in Louisiana (HEAL) observational study. Dust (indoor) and air (indoor and outdoor) samples were collected at baseline of 6 and 12 months. Dust samples were evaluated for dust mite, cockroach, mouse, and Alternaria by immunoassay. Air samples were evaluated for airborne mold spore concentrations. Overall, 89% of the children tested positive to ≥1 indoor allergen, with allergen-specific sensitivities ranging from 18% to 67%. Allergen concentration was associated with skin sensitivity for 1 of 10 environmental triggers analyzed (cat). Asthma symptom days did not differ with skin test sensitivity, and surprisingly, increased symptoms were observed in children whose baseline indoor airborne mold concentrations were below median levels. This association was not observed in follow-up assessments. The lack of relationship among allergen levels (including mold), sensitivities, and asthma symptoms points to the complexity of attempting to assess these associations during rapidly changing social and environmental conditions.

Partnership for front-line success: a call for a national action agenda on workforce development.

Despite more than a decade of dialogue on the critical needs and challenges in public health workforce development, progress remains slow in implementing recommended actions. A life-long learning system for public health remains elusive. The Centers for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry in collaboration with other partners in federal, state, local agencies, associations and academia is preparing a national action agenda to address front-line preparedness. Four areas of convergence have emerged regarding: (1) the use of basic and crosscutting public health competencies to develop practice-focused curricula; (2) a framework for certification and credentialing; (3) the need to establish a strong science base for workforce issues; and (4) the acceleration of the use of technology-supported learning in public health.

Biomedical testing of the kidney for persons exposed to hazardous substances in the environment.

To identify kidney injury and dysfunction among persons exposed to hazardous substances in the environment, a battery of biomarker tests has been identified for systematic public health use. The standardized use of tests for conducting field epidemiology studies was reviewed in a 1995 joint American-European workshop, and recommended tests were selected by the Agency for Toxic Substances and Disease Registry (ATSDR) and the Centers for Disease Control and Prevention (CDC). These tests would be useful in conducting public health activities but are not recommended in a manner that would suggest changes in routine clinical practice. The tests selected include serum creatinine, urine analysis, urinary albumin, retinol-binding protein, N-acetyl-beta-D-glucosaminidase (NAG), alanine aminopeptidase (AAP), and osmolality. Urinary creatinine was also included to adjust for urine concentration. The tests were chosen for use not only in epidemiologic field studies but also clinically oriented population screening and case studies of persons exposed to hazardous substances at waste sites. Studies using the battery may address the relationship between kidney damage and dysfunction and exposures to hazardous substances, especially in susceptible populations including children. Also, longitudinal studies should be conducted to evaluate the long-term health implications of abnormal tests and to measure the tests' predictive value for renal injury. These studies could evaluate the continuum of renal dysfunction as expressed by persistent decrements in glomerular filtration to the development of end-stage renal disease.

The findings of the Agency for Toxic Substances and Disease Registry Medical Waste Tracking Act report.

The Agency for Toxic Substances and Disease Registry (ATSDR) report "The Public Health Implications of Medical Waste: A Report to Congress" has been finalized and submitted to Congress. The report is a comprehensive review of all available data and information on the subject. Based on the data developed in the report, ATSDR concludes that the general public is not likely to be adversely affected by medical waste generated in the traditional health setting. However, the increase of in-home health care and other sources of nonregulated medical waste (e.g., intravenous drug users) provides opportunities for the general public to contact medical waste. In addition, ATSDR concludes that public health concerns exist for selected occupations involved with medical waste. These populations include janitorial and laundry workers, nurses, emergency medical personnel, and refuse workers. The ATSDR report also defines what material should be managed as medical waste and identifies research needs related to medical waste.