Response to the challenges of pandemic H1N1 in a small island state: the Barbadian experience

Pre-pandemic influenza preparedness is regarded as a critical function of public health [1] but in the midst of difficult economic conditions it can present a significant challenge to both developed and developing nations. To effectively detect a potential pandemic in the earliest possible stage, international health organizations recognized the need for all countries, regardless of size, to develop sensitive surveillance systems to be able to detect the entry of novel viruses into the population [2].

Barbados is the most easterly island in the Caribbean Sea, measuring 166 square miles with an estimated mid-year population in 2009 of 275,719 [3]. Barbados’ per capita GDP was USD 11.9 thousand in 2009, and approximately eleven percent of total government expenditure is spent on health care [4]. Primary health care is available to all citizens free of charge through government run community based health centres (polyclinics). Alternatively, persons may also access primary health care through a thriving private sector. In 2009, the island was regarded as having a very high human development, ranking 37^th on the Human Development Index scale [5].

Having been overwhelmed by the complexity of the response needed for the severe acute respiratory syndrome (SARS) epidemic, Barbadian public health professionals put various measures in place to improve its response in the event of a pandemic. In accordance with the resolution at the 58^th World Health Assembly (WHA) entitled Strengthening Pandemic Influenza Preparedness and Response[6], Barbados developed a National Influenza Pandemic Preparedness Plan (NIPPS) in August 2006 [7]. In September 2007, a pandemic flu outbreak training workshop was held and a pandemic manual was subsequently developed. This manual was later revised by a team of managers of the public community health centeres, and a two day seminar was held in April 2009 for private and public sector health care professionals to launch this protocol and to educate participants regarding the appropriate response to dangerous infectious diseases. These measures were accomplished through technical cooperation with the Pan American Health Organization (PAHO) and the Caribbean Epidemiological Centre (CAREC).

In 2007, the National Influenza Surveillance System was revitalized beginning with surveillance of cases of acute respiratory illness (ARI) at the countries eight community health centres which served as sentinel sites. These sentinel sites (polyclinics) are located at strategic points across the island (Figure 1). This was expanded in January 2008, to include the island’s lone tertiary public hospital where cases of severe acute respiratory illness (SARI) are detected routinely through active surveillance.

Barbados’ NIPPS plan follows international guidelines with recommendations for both pharmaceutical and non-pharmaceutical interventions to be implemented at various stages of a pandemic. In April 2009, when the World Health Organization (WHO) announced that the world was experiencing an influenza pandemic, Barbadian public health officials responded to the threat. In this paper, we examine the response of public health professionals in implementing plans regarded as best practice for developed nations and consider the peculiarities of implementation in a small island state.

Data for this study was collected using Barbados’ National Influenza Surveillance System which is comprised of ten sentinel sites, responsible for sending weekly notifications to the Ministry of Health of ARI and SARI Using guidelines provided CAREC [8], a case was reported as an ARI if it met the following case definition: acute (sudden) febrile illness (>38.0°C or 100.4°F) in a previously healthy person, presenting with cough or sore throat with or without respiratory distress. Cases were reported as SARI if they presented a sudden onset of fever over 38°C, cough or sore throat, shortness of breath or difficulty breathing, and required hospital admission.

During the pre-pandemic period, as part of routine surveillance, nasopharyngeal swabs were taken from all cases of SARI detected at the hospital sentinel site and a sample of six swabs from patients meeting the criteria of ARI from two of the most centrally located ambulatory sites. In April 2009, after the announcement by the WHO that the world had entered pandemic phase five, an enhanced testing strategy was introduced and all primary health care facilities, both private and public, were asked to take nasopharyngeal swabs from all persons who presented with fever (>38°C) with respiratory symptoms and a travel history to an affected area. When sustained community transmission of 2009 H1N1 was established, this testing strategy was returned to the pre-pandemic level.

Nasopharyngeal samples taken from suspected cases were sent first to the Barbados Public Health Laboratory (local) where they underwent preliminary screening using immunofluorescence testing. Using this method, it is possible to detect influenza A virus, adenovirus, respiratory syncitial virus, parainfluenza types 1, 2 and 3 and influenza B. All samples which met the criteria for testing, irrespective of result, were sent to CAREC. At the peak of the epidemic in the Caribbean, Barbadian health officials began sending some samples to the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia in an attempt to reduce the burden being placed on CAREC. The CDC and CAREC collaborated during the outbreak to provide critical guidance and technical capacity to the region.

During the pandemic, the Ministry of Health’s public health officials convened meetings of the National Pandemic Planning Committee which met at least weekly for the first two months of the declaration of a pandemic and then monthly for the duration of the outbreak in Barbados. A smaller Technical Command Committee was also convened to manage the response to the pandemic and met weekly. At the end of the outbreak period in Barbados, a formal evaluation was conducted by many of the major stakeholders within the health sector. The pharmaceutical and non-pharmaceutical interventions (NPIs) implemented as a result of these meetings form the basis of the results presented in this paper.

The evidence surrounding the use of some NPIs to delay spread of infection in a pandemic has been found to be weak [9],[10],[11]. Aledort et al. published a systematic review which examined the literature and also made recommendations based on expert opinion in cases where there were no or very low quality articles available as a study. Here we consider the pharmaceutical and non-pharmaceutical interventions carried out by the Government of Barbados through the Ministry of Health, and compare these interventions to the recommendations of the article by Aledort et al [9].

Generally, public health leaders in Barbados responded quickly and decisively to the threat of pandemic 2009 H1N1. Protocols were developed, disseminated and adhered to in the majority of the private and public sector. The response was characterized by technical cooperation between public and private sector within the country as well as regional (PAHO and CAREC) and extra-regional (CDC) alliances. The risk communication techniques employed served to construct and reaffirm partnerships and reassure the Barbadian public. One local newspaper produced a headline at the start of the outbreak remarking on the public’s “Calm Response to H1N1” [14].

For interventions with less conclusive scientific evidence, social and economic factors weighed heavily in deciding whether or not to include them. The use of rapid tests in the pre-pandemic and early pandemic phases was recommended Aledort et al [9]. However, the recommendation was made with the reservation that these tests often have suboptimal sensitivity [9, 22]. Several other sources advised against the use of these tests [16]. In Barbados, having weighed the benefits of rapid diagnosis against the high costs and wide margins of error, the use of rapid tests was decided against.

Aledort et al. recommended against the use of surgical and N95 masks for the general public at all pandemic phases with the exception of the advanced stage where it is stated that the evidence was inconclusive [9]. However, Jeff erson et al. have shown that in health care settings, the use of masks could reduce the transmission of influenza [23]. In Barbados’ response, persons entering health care facilities such as the polyclinics were asked to wear surgical masks.

It is difficult to determine the true impact of 2009 H1N1 as compared to regular seasonal influenza in the island since the National Surveillance System is still relatively new. In fact, virological surveillance was practically non-existent prior to the announcement of pandemic phase five. This component of surveillance was present in the protocol but lacked sufficient physician motivation and thus Ministry of Health officials used the opportunity of the emerging virus to encourage the taking of nasopharyngeal swabs.

The number of confirmed cases was small, but the significant surge in ARI and SARI cases noted at the sentinel sites indicate that the impact of the virus on the island was moderate. Barbados enjoyed excellent political commitment to the executing of its pandemic plan but was challenged by limited financial resources. As a result of 2009 H1N1, virological surveillance has improved significantly and local, regional and international partnerships have been forged and in some cases strengthened.