Jamaica: #Zika At The Beginning of September

After a hiatus of more than three weeks, Jamaica’s Ministry of Health (MOH) has posted a new zika update on its website. This update gives data received by the MOH as of August 26, 2016, which I have incorporated into the chart below:(The 8 reports are all posted on the MOH website, in the Press Releases section.)

More cases of zika than the numbers show

The numbers in this chart reflect the changing situation over a two month period regarding the zika outbreak. It is important to note, however, that the actual situation on the ground is vastly different for a variety of frequently articulated reasons:

• it is estimated that as many as 80% of people who become infected with the zika virus never show any symptoms, and therefore wouldn’t be represented in the  data;
• many people experience only mild symptoms during a zika infection and do not seek medical care;
• doctors and other medical staff do not necessarily report all those they suspect of having zika, although it is a Class 1 Notifiable disease, requiring notification within 24 hours.

Increasing numbers in two-month period

The increased numbers being reported are indicative not only of the actually increasing numbers of zika infections, but probably also of increased awareness of the disease, as well as increased reporting. The figures over the two-month period show the following:

• the numbers of zika notifications and suspected cases of zika have both more than doubled;
• the number of confirmed cases of zika has more than tripled;
• there has been a dramatic increase in suspected cases of zika in pregnant women, from 88 to 470;
• the number of confirmed cases of zika in pregnant women has increased significantly from 4 to 31.

Guillain Barre Syndrome – increased cases & 6 deaths

The number of Guillain Barre Syndrome (GBS) notifications has more than doubled during this two month period, as has the number of suspected cases among these notifications. Suspected cases are those that on further evaluation fit the case definition for GBS based on clinical signs, symptoms and investigation results. To date, zika has been lab confirmed in only 3 of these suspected cases of GBS.

However, the situation with GBS is of increasing concern, with Acting Chief Medical Officer Dr Winston De La Haye confirming that as of September 2 there have been 6 GBS-related deaths. In none of these cases has it yet been confirmed that the deceased had a zika infection; test results have come back negative in two cases and the results are pending in the others. The first of these GBS-related deaths was on June 26, and in this instance the deceased tested negative for zika, but positive for both dengue and chikungunya. The two most recent deaths occurred this week.

Communication in the context of zika

Earlier this week, the Opposition Spokesman on Health Horace Dalley (who is the former Minister of Health) made a public statement about the death of a patient at the Kingston Public Hospital (KPH) on Tuesday. Initially the MOH was unable to confirm the death. In subsequent interviews, Dr De La Haye said that communication with the MOH was being improved, as it was obviously a problem that Mr Dalley knew of the death at KPH, when he did not.

The MOH is also seeking to increase access to information about zika through the provision of two additional phone numbers that the public can call with questions about zika. This is being done through the MOH’s National Emergency Operation Center (NEOC) and is aimed particularly at providing information for pregnant women. The numbers are 537-1709 & 536-9125 and can be called Mondays to Fridays, 8:00am to 4:00pm.

I was very encouraged when the MOH began to post updates of the zika numbers on its website two months ago, and I was disappointed when the effort seemed to falter. I hope that the MOH will try to post the new figures regularly, perhaps on a weekly basis. This would be one useful – and fairly straightforward way – of providing ongoing data to the public.

 

 

 

Ministry of Health Jamaica: 6 weeks of #zika numbers

On July 5, the Ministry of Health (MOH) in Jamaica began posting updates on its website regarding the number of zika cases. The first update was for data as of June 25, 2016 and since then the MOH has posted a further 6 updates, the most recent of which was posted on August 8 and contained the numbers up to August 5, 2016. All 7 updates are currently available on the MOH website, but for easy review I have included the chart below:

One of the questions which remains for me is why there have been so few confirmed cases, given the steadily increasing numbers of reported and suspected cases. It would be useful for the MOH to publish data regarding the number of samples submitted for testing, the number of tests completed and the outcomes of these tests.

It would also be useful for the MOH to make public any reports on any problems being experienced with the testing that has been and is being done. I had asked some time ago, for example, about a doctor’s comment on having heard from two sources that a lack of a reagent had been hampering the testing of samples.

Dr Tufton had said via Twitter that he would check on that report. I haven’t heard an update from Dr Tufton on that reported lack of reagent, but it is entirely possible that I missed his update.

I heard CMO Dr De La Haye saying on a radio programme this morning (Nationwide News Network) that routine testing of all pregnant women could cost as much as J$100 million. If such an expenditure is being contemplated, it would be good to have an assurance that the process would be reliable.

The zika outbreak and its impacts continue to unfold, and the provision of information continues to be an important aspect of the government response.

 

Jamaica: Ministry of Health #Zika Virus Update – June 2, 2016

Last week Thursday morning (June 2, 2016), the Ministry of Health (MOH) held a press briefing to give an update on the current situation regarding the zika virus outbreak in Jamaica. Minister of Health, Dr Christopher Tufton, made an initial statement and was supported during the question and answer session  by MOH Permanent Secretary, Dr Kevin Harvey & Chief Medical Officer, Dr Winston De La Haye. Also participating in the briefing was Dr Noreen Jack, PAHO/WHO representative in Jamaica.

L to R: Dr De La Haye, Minister Tufton, Dr Harvey

Dr Tufton first gave his statement, the text of which can be seen on the MOH website, but he and others gave additional information during the briefing. He has also posted the link to his Periscope video of the briefing on his Facebook page. (The video does not contain the entire briefing; however, it contains a substantial amount.) Below is some of the information given during the briefing.

Ministry of Health Zika statistics as of May 29, 2016

• 1969 notifications
• 1387 notifications fit the case definition for suspected zika
• 465 suspected cases in Kingston & St Andrew
• 405 suspected cases in St Catherine
• 787 samples tested
• 403 test results received
• 16 positives for zika, with lab test confirmation
• 6 additional preliminary positives now being retested
• 2 pregnant women have tested positive
• all 16 positive cases have fully recovered

Dr Tufton said that 16 confirmed cases doesn’t reflect the reality on the ground, which is why the MOH is also giving the numbers of suspected cases at this time.

The MOH is also investigating clusters of people with rash that is suspected to be zika; these reports are coming primarily from the parishes of Kingston, St Catherine, Westmoreland and Clarendon.

Microcephaly & Guillain-Barre Syndrome (GBS)

At the briefing, an update was given on the two main complications of zika infection which have been of concern to the MOH, as they have been to the global community – microcephaly and GBS.  So far there have been no confirmed cases of microcephaly or GBS linked to zika virus in Jamaica.

Microcephaly

• 1 case of microcephaly reported; on investigation  found to be negative for zika. Woman would have become pregnant before zika reported in island.
• Dr Harvey noted that there is no baseline data for microcephaly in Jamaica, as it is not a reportable condition.
• MOH is now going back and doing docket searches to establish a baseline.
• The head circumference of all babies born in medical facilities is now being measured.
• MOH will be monitoring carefully, particularly from September onwards, which will be 9 months since first confirmed case of zika.

GBS

• 7 cases of GBS are currently being managed; 3 at Spanish Town Hospital, 3 at Kingston Public Hospital (KPH) & 1 at University Hospital of the West Indies (UHWI).
• Results as at June 1, 2016 showed that the patient at UHWI and 2 of the patients at Spanish Town Hospital are zika negative.
• Since start of 2016, MOH has been actively searching for cases of GBS. So far 13 investigated, 6 of which also tested negative for zika.
• Dr Tufton cautioned that a negative zika test does not absolutely rule out zika association, due to the short window of 3 to 5 days for testing.

Going Forward: The 2nd Phase of the Outbreak

During the second phase of its activities, the Minister indicated that there will be more focus on pregnant women and their partners, as well as those who develop severe complications such as GBS. The MOH will continue “to engage the population and stress the importance of taking personal responsibility.”

Among the activities listed were the following:

• Employing 1000 temporary workers to support the public health team in engaging in island-wide community vector control and public education activities.
• Hosting island-wide education sessions working through agencies such as the Social Development Commission, Neighbourhood Watch and the police to get to communities.
• Continuing the monitoring of pregnant women at the community level throughout their pregnancies including providing them with educational support.
• Providing 20,000 bed nets over six months to all pregnant women who visit antenatal clinics; these nets have been obtained with the help of Food for the Poor.
• Carrying out Vector Control activities through ‘fogging’ and larvicidal activities.
• Conducting heightened House to House Surveillance in sections of the population where the infection has been notified and/or confirmed.
• Working with the international partners such as PAHO/WHO/CARPHA/CDC to ensure that MOH actions are aligned with international standards and best practices.

Dr Harvey noted that reporting of zika cases is currently a manual process, but that the MOH is working on a web-based form, which it intends to roll out in a couple of weeks. Dr De La Haye indicated that some doctors have said that they find the form long & that a review is underway. He also reiterated that the MOH doesn’t wait for confirmation of zika cases before it takes action, but acts on reports of suspected cases. He said that some doctors have indicated that they are seeing as many as 20-25 cases of zika per day.

One question from a reporter was whether there has been a decrease in the number of pregnancies, given the MOH advice to women earlier this year to delay pregnancies. Dr Harvey responded that what is counted is births, and so any such decrease could only be noted later in the year. (Dr Tufton had indicated earlier in the briefing that there are approximately 40,000 births annually in Jamaica.)

The Olympic Games in Brazil

In response to a question, Dr Tufton said that the MOH did have concerns about our athletes going to the Olympics and continued to monitor the international debate regarding postponement of the games, though not a part of such discussions. He said that the MOH would be proactive in ensuring that athletes and supporters were given appropriate information and support, and that they understood the risks. On their return, people would be monitored for zika symptoms.

Dr Jack added that at this point WHO advice is not to stop the Olympics. She said that 60 countries have active zika transmission and that the risk of visiting Brazil is no greater than visiting any other country with active transmission. She said that current advice is that pregnant women not travel to countries with active zika transmission; others may travel, but are advised to take the recommended precautions to prevent being bitten by mosquitoes. It is advised that people are monitored for symptoms on return and that they abstain from sex or have safe sex for a month to prevent sexual transmission of zika.

(Last week a WHO spokesperson said that the Emergency Committee on zika will discuss concerns about zika and the Olympic Games at a meeting in June.)

Dr Tufton said that he will be giving a report on zika to Parliament on Tuesday,  June 7 and will give additional details during that report.

 

PS: Live Coverage of Media Briefing 

On the morning of the briefing, I called both the Jamaica Information Service (JIS) and the Public Broadcasting Corporation of Jamaica (PBCJ) to find out if either would be carrying live coverage of the event. I was very disappointed to find out that neither agency planned to do so.

I certainly appreciate the live coverage that did take place:

• Minister Tufton carried the briefing live via Periscope on his Twitter account: @christufton
• Jamaica News Network (part of the RJR Group) carried live coverage on television & online
• Power106FM interrupted their regular programming to carry part of the briefing live.

It is not acceptable, however, that a public health briefing of this nature and importance was not carried live by either of the government broadcasting agencies.

 

 

350 Words Or Less: Where Are We With #Zika Outbreak in #Jamaica?

Last night I was very puzzled when I took a look at PAHO/WHO’s Zika – Epidemiological Update  for April 28, 2016. These updates are posted weekly on their website.

PAHO/WHO Epidemiological Alerts and Updates

In the section on Incidence and Trends, the April 28 Update had the following about Jamaica:

Where exactly do we stand in terms of the Zika outbreak in Jamaica? This report seems to be saying that the outbreak here began in October 2015 (EW 39), when there was one reported suspected case. The highest number of suspected cases (162) was reported in the first week of February 2016 (EW5), with decreasing numbers of suspected cases susequently. Is this pattern agreed by the Ministry of Health (MOH)? If so, what does this mean in terms of expected incidence of zika? And if not, what does the MOH say about where we are in terms of the outbreak?

The number of suspected cases I have mentioned are taken from an interactive graph on the PAHO/WHO site. Pointing to each bar in the graph  gives the number of confirmed and suspected cases reported for that week.  PAHO/WHO interactive chart of suspected & confirmed Zika cases 

 

 

Unfortunately the MOH website doesn’t provide any such data. In a situation as rapidly changing as the zika outbreak is, it isn’t acceptable that the Ministry’s website isn’t being updated regularly in respect of this and other viruses (dengue and H1N1 influenza in particular) now circulating in Jamaica.

MOH representatives, including Minister Tufton, CMO Dr De La Haye and Director of Health Promotion and Protection Dr Copeland, seem to be readily available to the media, and are often heard giving updates. They share data about samples for testing and confirmed cases, etc. But this data is not posted to the website, where it can be accessed in more permanent form. The MOH website should be the go-to source for this kind of information.

NB As of today, there are still only 8 confirmed zika cases for Jamaica. But how many suspected cases are there? You can find a news report on Irie FM, for example, but not on the MOH website.

Enter a caption

 

 

 

 

But Won’t They Panic If We Tell Them?- Communication re #ZikaVirus & other health emergencies

I found myself nodding in agreement frequently as I watched a presentation given by Dr Barbara Reynolds at the US Centers for Disease Control & Prevention’s (CDC) Zika Action Plan Summit which was held in Atlanta, GA on April 1. The title of Dr Reynolds’ talk was “Crisis and Emergency Risk Communication: What the public needs when risks are uncertain”. (Scroll down for link to presentations.)

As I watched the live stream of the presentation, I kept thinking back to a number of public health situations in the past couple of years when the Jamaican public would have benefited from better communication by Government agencies:

• the chikungunya/ChikV epidemic in 2014
• the Riverton dump fire in 2015
• the problems in health facilities & deaths of premature babies in 2015.

And although the current situations with Zika virus and H1N1 influenza virus are being handled significantly better, there are still some ways in which communication can be improved.

Dr Barbara Reynolds’ Presentation

Dr Reynolds defined crisis and risk communication as “the kind of communication that leaders will do, along with their experts, to help people and communities make the best possible decisions when the information is imperfect and we’re under impossible time constraints.”  Early in her presentation, she made a very important statement:

“And it may be actually surprising to learn that people can accept bad news more easily than they can accept uncertainty.”

 

I didn’t actually find this surprising, as from experience I know it is true. With bad news, you know more clearly where you stand and what actions you need to take; with uncertainty, you don’t know where you stand and decisions about what actions to take are that much more difficult. Dr Reynolds emphasized that during such times the public need to have the facts and need to be empowered by having not just the how of what to do, but also the why.

 

In discussing common communication failures, she noted that “a poor operational response cannot be saved by good communication….[and] a good operational response can be spoiled by poor communication.” Numbers 2 and 3 on this list  – late release of information & paternalistic attitudes – certainly were among the problems with the communication responses we experienced during the three health crises I mentioned earlier.

 

Dr Reynolds  said she had seen over the years that:

“people often talk about changing messages based on the fear that people will panic. Panic behaviour is actually very rare, but if it does happen the research tells us it happens when there’s no credible authority  and all options seem equal. So what we should be working towards is being as credible as possible at every stage along this response.”

She discussed six principles of Crisis and Risk Communication, which were a useful framework for developing messages.

The issue of credibility and trust was raised repeatedly, and the need for these qualities in leaders and spokespersons communicating with the public. Dr Reynolds stated that:

“Condescension is the number one failure in good communication in a response.” 

She shared a number of communication lessons particularly relevant to the developing situation with Zika, where there is a lot still not known about the virus and knowledge is being added to almost on a daily basis.

Dr Reynolds began with and ended with the following message:

Jamaica’s Communication Responses

I believe lives were lost because of both the poor operational response and communication response to the ChikV epidemic. Despite prior warning years before, the Jamaican Government failed to prepare adequately for the possibility of an epidemic. And the poor communication response failed to inform the public adequately about the risks. The initial messages downplayed the risks, which was particularly dangerous for those with pre-existing medical conditions and vulnerable groups such as the elderly. There was also a failure initially to inform the public about the possible medium and long term effects ChikV could have on a percentage of people.

That experience has had an impact on the response to Zika virus to date, not solely because of the toll it took on the lives and health of Jamaicans, but also because of the political fallout. As continues to be shown , the full impact of Zika is not yet known to the scientists and medical practitioners, the public health authorities and political leaders or the public. In this situation, with more possible impacts being discovered and discussed on an ongoing basis, it is essential that the public is kept informed and updated.

Minister Tufton & CMO De La Haye

Former Minister Dalley

Public health spokespersons have been far more visible and accessible, both regarding Zika and the H1N1 flu virus since the start of 2016. It is good to see and hear from the Ministry of Health’s current Chief Medical Officer Dr Winston De La Haye and other Ministry spokespersons on radio and TV and in the print media. Both the current Minister of Health Christopher Tufton and his predecessor Horace Dalley learned lessons from the experience of Dr Fenton Ferguson, whose handling of the ChikV crisis was devastating. I know that Jamaica has experts with the skills and experience to handle communication during public health emergencies, and we must benefit fully from this expertise.

One way in which we need to improve is in making information accessible in more permanent and official ways. For example, although Dr De La Haye and other Ministry of Health representatives give updates about numbers of confirmed cases, number of samples tested, etc, this data is not routinely made available on the Ministry’s website. So if you miss the update in the media, there isn’t a clear place to go to to retrieve it. It is also important that the public aren’t left to guess when the next update will be. More information is also needed regarding Jamaica’s state of readiness to deal with a possible increase in cases of microcephaly, Guillain-Barre Syndrome and other neurological disorders being associated with Zika virus outbreaks.

Zika virus is being increasingly regarded as a puzzling and complex virus, with possible severe effects, despite its relatively mild symptoms. Effective communication with the public is essential, though challenging.

Links to CDC Presentations

Dr Reynolds’ presentation is available here.

 Video recording of Dr Reynolds’ presentation available here. (Starts at 3:54)

 Link to CDC Zika Action Plan Summit page with presentations & other resources

 

 

 

#ZikaVirus Update: Jamaica, Caribbean & Beyond

The news regarding the Zika virus is being updated all the time. Underlying the updates is an acute awareness of how much is not yet known about the virus and its effects, how much there is still to learn. Almost on a daily basis, new information about the virus’ spread is reported. In this post, I’ll touch on a few of these updates.

Jamaica: 7 weeks after 1st confirmed case of Zika, 4 new cases confirmed

Up until Thursday, March 17, 2016, Jamaica had one confirmed case of Zika virus, a case which had been confirmed on January 29. The 4-year-old child had started to show symptoms on January 17. This was the first confirmed case and remained the only confirmed case for the following 7 weeks.

As I was driving to a Technical Update on Zika, Gillain-Barre & Microcephaly being held on the evening of March 17 at the Faculty of Medical Sciences at the University of the West Indies (UWI) Mona, this was the foremost question in my mind: Why hadn’t there been any further cases of Zika reported? I wondered what explanations the experts might have for this.

The Technical Update was a collaboration by UWI, the Ministry of Health and PAHO/WHO. A PAHO/WHO technical team was in Jamaica for consultations and the opportunity was seized to have an update which was open to the public.

Dr Winston De La Haye, Chief Medical Officer, was chairing the proceedings and after the opening remarks, the first presentation began. Dr Stephane Hugonnet of WHO presented on Zika and arbovirus surveillance, microcephaly and other neurological disorders – recent evidence & implications for health systems. 

At the end of his update regarding the global situation, Dr Hugonnet made some comments about the situation regarding the Zika virus in Jamaica. He said that for Jamaica, the epidemic curve of about 95 suspected cases showed a sharp increase, with a peak in week 5, which corresponded with the week in which there was the first confirmed case at the end of January.  This was then followed by a decrease in suspected cases.

 

 

Dr Hugonnet said it was very surprising that there hadn’t been any other cases and it was hard to understand having only one case. He said that the surveillance system was working well, and there were suspected cases of dengue, chikungunya or fever and rash that were being picked up and sampled.

He said that it was a priority to assess whether or not the Zika virus was circulating in the country and that it was necessary to strengthen the investigation around the index case, including retesting to check if it was indeed positive. He also advised sampling of the negative tests to see if they were really negative.

Once it was established that the virus was circulating in Jamaica, there would be no need to keep testing all cases. It would then be necessary to monitor the trend of the epidemic and the geographical spread. It would also be necessary to monitor pregnant women and cases of Guillain-Barre Syndrome (GBS), and to establish baseline data for microcephaly and GBS.

At the end of Dr Hugonnet’s presentation, Dr De La Haye resumed the podium to continue his duties as Chairperson. In a rather dramatic turn of events, he told the gathering that on his way to the symposium, he had actually received information that 2 new cases of Zika had been confirmed. This meant that the country now had a total of 3 confirmed cases. He noted that the 2 cases had been confirmed by the recently upgraded Virology Lab at UWI, saying that it was an advantage to have a shorter turn around time for getting test results. (See JIS report regarding UWI Virology Lab upgrade)

Ministry of Health press briefing on Zika virus, March 18, 2016 (Far left: Dr De La Haye. 2nd from left Minister Tufton.)

By the time the Ministry of Health held a press briefing the following afternoon (Friday, March 18), the number of confirmed cases had increased to 4. Remarks by Minister of Health Dr Christopher Tufton at Zika press briefing – 18-3-16 By the post-Cabinet press briefing on Tuesday, March 22, another case had been confirmed, bringing the total to 5. Four of the cases were in Portmore, St Catherine and one was in Lyssons, St Thomas. And it is expected that the number of cases will increase.

Representatives of the Ministry of Health have been doing many media interviews, outlining the steps being taken by the Ministry regarding the increased number of cases and reiterating the ongoing public health messages about reducing the risks of being infected by the Zika virus.

Caribbean Public Health Agency Update on Zika in the Caribbean

On March 23, 2016, the Caribbean Public Health Agency (CARPHA) posted a short video in which Executive Director, Dr. C. James Hospedales provided an update on the Zika virus in the Caribbean region. (Click here for video.)Some points made by Dr Hospedales:

• 15 countries in the region have reported cases of Zika virus transmission in their countries/territories.
• Microcephaly & Guillain-Barre are rare conditions and are not required to be reported in the Caribbean region, so there is little baseline data on these conditions.
• CARPHA is now in the process of setting up collection of baseline data.
• The Caribbean is vulnerable to Zika virus for a number of reasons: a susceptible population which has not met the virus before, wide spread Aedes aegypti mosquitoes & a lot of travel in and out of the region.
• In another 2 months, many of the countries will see the start of the rainy season, which will increase possibilities for increased mosquito breeding.
• The two most important messages for stopping the spread of Zika are stopping the mosquito breeding & stopping the mosquitoes biting.

CDC Issues Updated Zika Recommendations to do with Pregnancy and with Sexual Transmission

On March 25, 2016, the US Centres for Disease Control & Prevention (CDC), issued an update of its recommendations regarding aspects of Zika Virus. (Click here for full update.)

The updated recommendations, which are worth reading in full, are given under 3 headings:

Article 1: Updated interim guidance for pregnant and reproductive age women

Includes the following:

Article 2: Updated interim guidance for preventing sexual transmission of Zika

Includes the following:

Article 3: Increasing access to contraception in areas with active Zika transmission

Includes the following:

(It is significant to note that more than 50% of pregnancies in Jamaica are unintended, which impacts the public health education regarding Zika and pregnancy here also.)

As the spread and impact of the Zika virus continues in the region, we in Jamaica need to keep informed and act on the information to best protect ourselves from this new personal and public health challenge.