Zika virus disease-knowledge, attitudes and practices among pregnant women-implications for public health practice.

OBJECTIVE: Mosquito-borne diseases continue to pose a threat to Latin America and the Caribbean. Zika virus disease entered the Caribbean in 2013 with increased reporting of cases across the region in 2016, affecting more than 50 countries. This study aimed to ascertain the knowledge of, attitudes and practices towards Zika virus disease among antenatal clinic attenders in Trinidad and Tobago during the 2016 outbreak. STUDY DESIGN: A cross-sectional questionnaire survey was undertaken. METHODS: A knowledge attitudes and practices survey was conducted among antenatal clinic attenders at publicly funded primary care health centres. All counties of Trinidad (except St Patrick, Caroni and Victoria) and Tobago were included in the study. Within each county, three health centres were selected at random. At the antenatal clinic of each selected health centre, antenatal clients were selected by randomly selecting their patient file from that day's antenatal clinic patient files. Data collection occurred from September to November 2016. The knowledge, attitudes and practice survey was administered by an interviewer-administered questionnaire. The World Health Organization Knowledge, Attitudes and Practice surveys Zika virus disease and potential complications Resource pack was adapted for use as the data collection tool. All data collected were analysed using SPSS software, version 23. Tests with P-values less than 0.05 were deemed significant. RESULTS: Seventy-four percent (74%) of responders did not think there was a link between sexual transmission and Zika. About 19% stated that abstaining could prevent Zika but only 6.6% actually practiced this. Seventy-six percent knew the risk of microcephaly, and this knowledge of the risk of microcephaly was found to be significantly associated with the number of weeks' gestation. Less than 40% knew the risk of Guillain-Barre syndrome. Doctors at health centres followed by private doctors were the top two trusted information sources for responders. Responders thought that the government could spray insecticide, clean drains, educate community members and clean overgrown vacant lots of land. CONCLUSION: The government and healthcare workers need to reach specific target groups with accurate messages to minimize the associated morbidity and thereby safeguarding national and global health security.

Blood donors' attitudes towards voluntary non-remunerated donation in Trinidad and Tobago.

OBJECTIVES: To assess the attitude towards voluntary non-remunerated blood donation among blood donors in Trinidad and Tobago (TRT). BACKGROUND: Blood donors in TRT are either family replacement (F/R, 87%) or remunerated (13%). There is chronic blood shortage and high seroreactivity for transfusion-transmissible infections (TTI) in donors. Converting existing to voluntary non-remunerated donors (VNRD) reduces the need to recruit news donors in achieving 100% VNRD. METHODS: A questionnaire-based, cross-sectional survey was conducted at two blood collection centres at an interval of 8 years. Donors were surveyed for sociodemographic characteristics, awareness of the blood shortage, previous donation behaviour, donor-beneficiary linkage if F/R, willingness to become VNRD and choice of motivators for converting to VNRD. RESULTS: A total of 400 and 595 donors respectively participated in Surveys 1 and 2, of whom 92·8 and 86·3% were F/R (P < 0·001), respectively. In both surveys, 52% of participants were unaware of an existing blood shortage (P = 0·983). Only 9·8 and 9·1% of participants expressed unwillingness to become VNRD (P = 0·720). The main motivators to convert to VNRD were reminders from the centre (84%) and extended opening hours (78%) in Survey 1 as compared to confidence that donated blood was used properly (73%) and shortened waiting times to donate (73%) in Survey 2. CONCLUSION: Despite low awareness of blood shortage, willingness to become VNRD was high among existing donors. Accountability and donor convenience underpinned the main motivators for converting to VNRD.

Dengue Deaths: Associated Factors and Length of Hospital Stay.

Background. Dengue continues to pose a public health problem globally. Objective. To review factors associated with patients who died from dengue in Trinidad. Methods. A retrospective case note review of hospitalized patients who died during 2001 to 2010. Results. A total of 23 cases were identified: 13 males, 10 females-12 East Indians, 9 Africans, and 2 unknown. More than half (n = 17) were over 40 years of age with 10 being over 60 years of age; three were children. A falling platelet count was observed in 16 while 18 patients had a low normal haematocrit. There was a significant association of ethnicity, hypertension, and diabetes with length of hospital stay. Conclusions. The study sample included 10 patients over 60 years of age. Patients with diabetes and hypertension and patients of East Indian origin appeared to have a shorter hospital stay prior to death.

Public versus private healthcare – Views of doctors, nurses and the public

Objective: The study investigates the perception of publicvs private healthcare among doctors, nurses and the publicin Trinidad.Subjects and Methods: A cross-sectional study wasconducted on a sample of 1222 persons. Respondents wereasked via interviewer-administered questionnaire whichhealthcare system (public or private) they would chooseand why, if ability to pay was not a factor. They were alsoasked to state what in their view would improve thesystems. The data collected were subject to the Chisquaredtest and Fisher’s exact test to determine anysignificant associations.Results: One thousand two hundred and twenty-twopersons were interviewed (response rate 89%). Themajority of all groups would choose private healthcare (÷2= 238.06, df = 7, p-value = 0.000). The majority of nonmedicalgroups perceived private care to be faster andbetter (p = 0.000); doctors would like more accountabilityin private settings and more drugs and equipment in thepublic sector, while non-clinical groups wanted cheaperprivate care (p = 0.000).Conclusion: The publicly funded healthcare system seemsto be falling short on some quality standards, thus contravening a fundamental human right. The publicshould be informed when making a decision to opt forprivate care that the same doctors often work in bothsettings. For critical care, the public institutions have abetter staff complement, although this study highlightedthe need for more drugs and better equipment. Thegovernment needs to look closer at the reasons all groups,including doctors and nurses, would choose privatehealthcare.

Association between obesity and lung function among teenagers in Trinidad

OBJECTIVE: To examine association between obesity and lung function among teenagers in Trinidad. SUBJECTS AND METHODS: This study is part of an ongoing five-year cohort study in which five schools in the St.George East educational district of Trinidad were selected and students entering form one were followed up to form three (2012 to 2015). A questionnaire was completed on previous pulmonary disorders, eating and exercise habits along with demographic data. Data were available on 584 male students and 502 female students for three years. Descriptive analyses were performed according to year. General linear model analyses were performed to determine relationship of lung function variable ratio (forcedexpiratory volume in 1st second/forced vital capacity[FEV1/FVC]) to independent variables. RESULTS: Analysis of variance, according to year, showed that among the male students, FEV1, FVC, forced expiratory flow (FEF), peak expiratory flow rate (PEFR)in L/min, waist circumference, diastolic and systolic blood pressure, age and FEV1/FVC (%) were significant,whereas moderate exercise, FEV1, FVC, FEF, PEFR, age and FEV1/FVC (%) were significant in female students. The mean (year of study) PEFR in males were 285 (1), 302(2) and 384 (3). The mean (year of study) PEFR in females were 273 (1), 278 (2) and 338 (3). General linear model analysis showed PEFR to be a common significant factor for FEV1/FVC in both male and female students. In addition to PEFR, age, body mass index (BMI)-for-age-Zscore, ethnicity and interaction of religion and ethnicity were also significant among females. CONCLUSION: Based on results, BMI-for-age-Z-score issignificantly associated with FEV1/FVC in female students, but not in male students.

Quality of street food in Trinidad

OBJECTIVE: This study investigated the effect of a public health intervention on the environmental conditions under which street-vended foods were prepared and offered for sale. DESIGN AND METHODS: A before and after cross sectional study was conducted on a sample of 80 itinerant food vendors in one County of Trinidad. Forty food samples were tested for the presence of three types of bacteria. Public health information was provided at the first visit to the food vendors. Four weeks later the same vendors were surveyed and further food samples taken. The data collected were subject to McNemar’s test to determine whether the proportions for the before and after measurements were significantly different. RESULTS: The findings demonstrated the presence of microorganisms with the potential to cause food borne illness in food offered by itinerant night vendors. The results also showed a significant increase in the number of units being registered (p < 0.001) and displaying food badges (p = 0.002) after the first interview. Similarly there were significant improvements in personal hygiene parameters reviewed at the second visit in terms of attire of vendors (p = 0.002); availability of potable water (p < 0.001); and the general appearance of the food handler (p=0.025). CONCLUSION: There appears to be a role for public health education sessions on food handling practices for food vendors. Government agencies should also provide premises for such food vending where there are ample and satisfactory water and sanitation facilities.

Dengue deaths: length of hospital stay, haematological parameters and presence of co-morbidities

OBJECTIVE: To review the characteristics of the patients who died from dengue in Trinidad to determine if there was any association between length of hospital stay, haematological parameters and ethnicity and any association with gender and the presence of co-morbidities. DESIGN AND METHODS: A descriptive study was undertaken via a review of case notes. Four major public hospitals were included in the study to locate patients who died from dengue between 2001 and 2010. RESULTS: The duration of hospital stay until death was characterised by a mode of 3 days and a median of 4 days. Eleven patients (47.8%) had a history of diabetes and 7 (30.4%) a history of hypertension recorded in the notes. A falling platelet count was observed in 69.5% of patients. A low normal haematocrit was observed in 78.2% of cases. Analyses did not reveal a significant association between length of hospital stay and platelet levels, nor with ethnicity; neither was a significant association found between gender and the presence of co- morbidities. CONCLUSION: Morbidity and mortality from dengue continue to pose a public health problem globally. Most patients had a history of diabetes with low platelets on admission, but low to normal haematocrit throughout their stay in hospital (mode 3 days). A prospective comparison study would better explore the significance of co- morbidities and the meaning of low to normal haematocrit levels.

Non-fatal suicidal behaviour: associated factors

OBJECTIVE: To investigate the factors that influence non-fatal suicidal behaviour. DESIGN AND METHODS: A cross sectional study was undertaken and data were collected from a review of medical records of patients in addition to structured interviews with patients using the Columbia Suicide Severity rating scale. RESULTS: The survey findings (n=20) revealed that one-quarter of patients had more than one attempt. More than one third of the patients began having suicidal thoughts years ago (n=9, 45%). Half of the responders had thoughts ranging from twice a week to many times a day and the thoughts lasted from one to four hours a day to most of the day in 60% of responders. Six patients told someone of their plan. While females used the method of overdosing on pills, males tended to drink a poisonous substance or use more lethal means of attempting suicide. From the case note review (n=42), more females (n=31, 74%) attempted suicide compared to males (n=11, 26%). CONCLUSION: These findings suggest there were factors that may highlight at-risk persons e.g. those with past attempts, and those who confide in others about their plans. It appears persons have suicidal thoughts for several years and the majority think about these on most days and these thoughts last at least 1-4 hours a day. There is therefore a role for health education to the public who need to be aware of warning signs and how to handle the situation if they are told about a planned attempt.

Correlates of vigorous physical activity in adolescents in five secondary schools in Trinidad

OBJECTIVE: To determine the correlates of vigorous physical activity in adolescents in Trinidad. DESIGN AND METHODS: Adolescents (n = 344) between 11-15 years from five secondary schools in North-central Trinidad were cross-sectionally surveyed. Behavioural risk factors: alcohol and smoking use, physical activity and diet were obtained by a pilot tested interviewer administered questionnaire. In addition, anthropometric measures were obtained on site at school. Multivariate logistical regression was used to analyze correlates of vigorous physical activity by sex. RESULTS: Fruit and vegetable intake (p < 0.001) and religion (p = 0.034) were correlated with vigorous physical activity in females. Lower waist circumference (p = 0.014), age (p = 0.046) and diastolic blood pressure (p < 0.01) were correlated with vigorous physical activity in males. Body mass index (BMI) for age data indicated that 41.3% of the children were overweight or obese. However, vigorous physical activity did not correlate with BMI for age in either sex. In the final logistic regression models, higher vigorous physical activity was associated with lower diastolic blood pressure in males (p < 0.05) and an increased daily intake of fruit and vegetables in females (p < 0.001). CONCLUSION: Increased dietary intake of fruits and vegetables in females and lower diastolic blood pressure in males were associated with higher vigorous physical activity. Prospective studies are required to determine and clarify the relative importance of diet and physical activity in overweight adolescents and their risk of chronic metabolic disease.

Investigation of dengue related knowledge, attitudes and practices among form three secondary school students in the seven counties of Trinidad

OBJECTIVE: To investigate dengue related knowledge, attitudes and practices among secondary school students in Trinidad. DESIGN AND METHODS: A cross-sectional study was undertaken. All counties were included; one school from each county was randomly selected. Form Three students of the 7 schools were invited to participate. Data collection was conducted using a questionnaire. RESULTS: Almost three-quarters of respondents (73.1%) demonstrated sufficient knowledge about dengue. There appeared to be a link with preventative practices among households and adequate knowledge. Moreover, students associated with persons who had been previously diagnosed with dengue demonstrated a greater level of knowledge than those without. In fact, the school with highest knowledge levels also had the greatest proportion who reported a relative with a past diagnosis of dengue. Furthermore, 53.3% agreed that dengue was a community concern, while 59.6% believed that control and eradication of the dengue vector was primarily the responsibility of Health Authorities. CONCLUSION: It appears that students with greater knowledge engaged in preventative measures and vice versa. Knowledge, attitudes and practices may be influenced by several rather than a single factor. With a greater proportion stating that vector control was the responsibility of the health authorities, the findings, though encouraging in parts, highlighted a need for further targeted health education measures.

Leprosy - knowledge, attitudes and practices among clinic attenders

OBJECTIVE: To investigate the knowledge, attitudes and practices among leprosy clinic attendees and to review the epidemiology of leprosy in Trinidad. DESIGN AND METHODS: A cross-sectional study was undertaken utilizing an interviewer administered structured questionnaire. All leprosy clinic attendees over the age of 18 years who attend 3 of the 5 leprosy clinics in Trinidad were included. Data were collected from April to July 2014. RESULTS: All 21 responders who were invited to participate agreed, giving a response rate of 100%. Fifty-two percent (52%) were unaware of how the disease is contracted. Most patients (81%) believed that educating the public would help eradicate leprosy-related stigma. Ninety percent (90%) reported that they were compliant with taking their medication and 86% reported that they attended all clinic appointments. The majority (76%) felt self-conscious about their disease and 50% have experienced negative feelings after diagnosis. CONCLUSION: Patients appear to be aware of signs and symptoms of leprosy but less so about transmission. There appears to be a need for educating patients about their illness as well as the public to reduce stigma associated with the illness. There was also a need for counselling of patients to minimize the reported distress, sadness and worry they experience after being diagnosed.

Tuberculosis – patients’ knowledge, attitudes and practices regarding their illness

OBJECTIVE: To determine tuberculosis (TB) patients’ knowledge, attitudes and practices with respect to their illness. DESIGN AND METHODS: A cross sectional study was conducted. 208 tuberculosis patients > 18 years of age who were currently receiving treatment were included. The study sample was selected from two major regional chest clinics in Trinidad. A pilot tested questionnaire was interviewer administered to each patient. RESULTS: Out of the 208 patients interviewed (response rate 65.0%), 129 were male, and 79 were female. The majority of patients had either secondary or tertiary level of education (54.8%), whereas only 43.8% had either primary level of education or none at all. Analysis revealed that TB knowledge was affected by a patient’s level of education, where persons with secondary/tertiary levels of education had a greater knowledge about TB (p<0.005). The majority (78.4%) of patients believed that they were not stigmatized; however, 191 (91.8%) patients urged for increased public awareness about TB in order to change perceptions toward the disease. The majority of patients were compliant towards their management advice, as well as taking their prescribed medications, however non- compliance was noted to be more likely in the under 50 year age group (9.8%), rather than the over 50 year age group (1.1%). CONCLUSION: Patients with at least secondary level education had better knowledge about tuberculosis than those with primary level education. Patients indicated the need for more public awareness about TB. Compliance with management (medication and attendance at clinics) was good among the majority of the patients.

The evidence base for healthcare related decision-making in Regional Health Authorities

OBJECTIVES: To evaluate the evidence base used in policy and healthcare decision making by the Regional Health Authorities in Trinidad. DESIGN AND METHODS: The study focused on the five Regional Health Authorities (RHAs) in Trinidad where senior administrative employees at each Regional Health Authority were purposively sampled and interviewed using a structured questionnaire. Responses were initially reviewed individually to determine types of evidence used within each RHA. All responses were secondly compared between the various RHAs. RESULTS: All RHAs participated; each had an observatory type unit which was responsible for data collection, collation and production of reports on an annual basis. Reports focused on the number of patients accessing services (e.g. specialist clinics and surgical procedures), patient demographics and patient access to health services. All RHAs had annual service agreements with the Ministry of Health which acted as a guide with targets and as a check on accountability of money spent. Decision making in each RHA was tiered by financial cap; most decisions were made by the Chief Executive Officer and/or Board of Directors within their caps; decisions requiring monetary investment over the RHA limit had to be approved by the Ministry of Health. CONCLUSION: This study revealed that RHAs had systems in place whereby they engaged in evidence-based practice utilising the Authority’s observatory data plus other information sources, ran trial periods and economic analyses for healthcare related decision making.

Preparedness of healthcare facilities for a public health emergency in a Caribbean country

OBJECTIVE: To review basic, critical elements of emergency preparedness and response capacity in the healthcare system of Trinidad and Tobago. DESIGN AND METHODS: A descriptive study involving one major hospital and one randomly selected health centre in each Regional Health Authority (RHA). Responders were chosen by purposive sampling and structured face-to-face interviews were carried out. Data collection was undertaken using modified versions of two previously validated data collection tools. RESULTS: All 5 hospitals in each RHA and 4 of 5 health centres participated. Emergency response plans existed in all healthcare facilities reviewed; however plans were not regularly tested. An investigation team can be assembled in 24 hours and a patient referral system was in place in all hospitals. There appeared to be access to stockpiles in all facilities. There was a gap in ongoing infection control measures including the absence of regular personal protective equipment (PPE) training for staff. CONCLUSIONS: There was an urgent need for systematic rather than ad hoc measures for testing existing plans and staff training in their roles and responsibilities during an acute public health event should one occur. For infectious diseases with high case fatality rates such as avian influenza and Ebola, it is critical for front line staff to be aware of infection control measures including how to properly use PPE. Governments should take the opportunity of the Ebola outbreak in West Africa to utilize public health capacity to catalyse the systematic strengthening of core capacities for alert and response to meet their International Health Regulations (IHR) 2005 obligations.

Challenges in investigating transient rash illness in nursery children.

INTRODUCTION: In October 2007, the Thames Valley Health Protection Unit (TVHPU) was notified by a parent that her child developed a transient rash after eating lunch at a nursery in Oxfordshire. An initial investigation undertaken by TVHPU was escalated when similar incidents were reported in nurseries in other parts of England. METHODS: A detailed epidemiological and food tracing investigation was conducted to ascertain the aetiology. RESULTS: Investigations revealed 11 incidents affecting 164 children between July and November 2007 in six nurseries operated by two companies. The symptoms included a transient rash around the mouth and hands of children who ate meals prepared on site by the nurseries. Consumption of the lunch main course appeared to be a strong aetiological factor. Expert opinion pointed to biogenic amines (e.g. histamine) as a possible cause for the symptoms displayed, but there was insufficient evidence to support testing of food samples. CONCLUSION: The incident highlighted significant gaps in reporting of unexplained symptoms among children in nurseries, indicating that such incidents do not always come to the attention of public health authorities. Timely notification to HPUs will enable prompt investigation, increase the likelihood of identifying the cause and inform appropriate responses to prevent future incidents.

Are we prepared for a deliberate release of a biological agent?

OBJECTIVES: Following the events of 11 September 2001 in New York, planning for the deliberate release of chemical, biological, radiological and nuclear agents has intensified in the UK, with Department of Health recommendations for National Health Service and public health action. A consequence of this was to assess preparedness across the West Midlands region of England for mounting an effective response to a deliberate release of a biological agent. STUDY DESIGN: Descriptive study. SETTING: West Midlands, UK. This work involved key organizations and entailed obtaining information from those responsible for and likely to be involved in managing incidents via questionnaire surveys based around preparedness and planning arrangements. RESULTS: Findings revealed that plans delineating action to take during an incident do exist. However, staff training (40%) in acute trusts and testing of plans in primary care trusts (45%) could be improved. Communication arrangements in hospitals require support. CONCLUSION: Work is ongoing but there is more to do. Trusts should provide staff training and engage in exercises to test plans and communication arrangements.

Chemical incidents: are we ready in the West Midlands? Testing the communication arrangements of on-call public health doctors.

Primary care trusts are responsible for handling major chemical hazards. This includes the testing and exercising of plans in a regular and routine manner. The Chemical Hazards and Poisons Division (Birmingham), which provides a 24-h, 365-day resource for the West Midlands region in the UK, undertook an audit to test the out-of-hours communication arrangements of public health doctors. The audit revealed that there is an urgent need to: (1) review contact details within on-call packs; (2) ensure that doctors performing on-call duties know, at the very least, the names of the primary care trusts/local authorities, county councils/other trusts in the area; and (3) ensure a failsafe method for contacting the person on call for public health.