Overview of cases
On June 3, 2009, Barbados reported its first case of 2009 H1N1. From June until October 2009 there were 155 confirmed cases of 2009 H1N1 (Figure 2). Since October 24, 2009, there has only been one confirmed case of 2009 H1N1, which occurred in January 2010. The cases range in age from 23-days-old to 65-years-old, with a mean age of 17-years-old; the greatest proportion of our cases occurred in the 5-14 age group and the second highest in the 15-24 age group. A little more than half (53.5%) of all confirmed 2009 H1N1 viral infections occurred in females. The most common presenting symptoms were fever - 92.9% (144 cases); and cough or sore throat - 82.6% (128 cases). Only 35.5% (55) of cases presented with gastrointestinal symptoms. Of the 155 confirmed cases, there were three fatalities, which occurred in persons with underlying chronic conditions, all of whom were morbidly obese.
For the outbreak period (June to October 2009), the surveillance team received reports of 2,483 cases, compared to 412 cases for the same period in 2008. There were 179 SARI cases from June to October 2009, 6% (10) of which required ventilation and care in the intensive care unit. During this time there were seven SARI deaths. Of these, four received nasopharyngeal swabs that were tested for 2009 H1N1 and three tested positive.
The total hospitalization rate due to SARIs for the year 2009 was 90.1 per 100,000 people, compared to 7.3 per 100,000 people for 2008. The highest hospitalization rate occurred in children less than one year (400 per 100,000) followed by those 1 to 4 years old (290 per 100,000).
Non-pharmaceutical interventions
Human surveillance
Case reporting and early rapid viral diagnosis
During the initial phases of the pandemic while knowledge of the virus’ characteristics was limited, all suspected cases in the island were reported to the Office of the National Epidemiologist and nasopharyngeal swabs taken. All cases suspected of having 2009 H1N1 were investigated and close contacts monitored until the results of the swab were obtained. As the outbreak advanced, only laboratory-confirmed cases and suspected hospitalized cases were reported. Immunoflourescent testing was done on the swabs in country to test for influenza A virus, but this test was incapable of subtyping and thus swabs had to be sent to a regional centre for real-time polymerase chain reaction testing to be done. This resulted in wait times for results that averaged one week but were occasionally as long as six weeks. Rapid testing was not utilized in Barbados.
Hand hygiene, respiratory etiquette and disinfection
The Ministry of Health placed great emphasis on hand hygiene and respiratory etiquette in its communication messages to the public. The WHO Outbreak Communication Guidelines[12] were used as the risk communication guide in responding to the emergence of 2009 H1N1 in our community. These guidelines use trust, early announcements, transparency, listening and planning as key components of risk communication [12]. Several protocols were distributed on hand hygiene to schools, day care centres, workplaces and the general public. An infectious waste protocol was developed to guide health facilities in the disposal of infectious waste.
Surgical and N95 masks and other Personal Protective Equipment
Personal Protective Equipment (PPE) was donated by the U.S. Agency for International Development (USAID) in May 2008 and USD 40,500 in supplies was approved for the financial year (2008/2009) and utilized in 2009/2010. During the pandemic large amounts of PPE were used in both the public and private sector and a protocol governing distribution and usage was developed and circulated. The central storage facility has been improved upon during this time but remains challenged by lack of security to prevent theft and insufficient human resources for efficient stock-taking.
Patient management
Isolation of sick individuals
As part of their efforts towards pandemic preparedness, the Ministry of Health in Barbados held a seminar in April 2009, at which they disseminated a manual on management of Dangerous Infectious Diseases to middle- and senior-level managers of at least 90% of health care facilities in the country. This manual provided detailed instructions to health care leaders on the structure and type of isolation facilities that ought to be available at their facility.
During the outbreak, health care facilities attempted to follow these evidence-based guidelines but were challenged in some regards by their existing structures and layout, and restricted by the high costs that would have been necessary to change these facilities. The island’s lone public hospital is the only major health centre with designated isolation facilities but its capacity was significantly overwhelmed during the outbreak. The community health centres created temporary isolation areas by reorganizing, and in some cases, curtailing routine services. Administrators and health care providers remained committed to the principles of patient isolation for dangerous infectious diseases and have stated their intention to revise their protocols so that there are evidence-based and yet feasible and practical for each facility.
Contact management
Quarantine and contact tracing
Ministry of Health officials took the decision early in the pandemic that there was insufficient evidence to support quarantining of asymptomatic persons who had been in contact with a probable or confirmed case or had travelled to an affected area internationally. The protocol adopted for contact tracing varied according to whether persons were regarded as probable or confirmed cases.
A probable case is an individual with an influenza test that is positive for influenza A, but is unsubtypable by reagents used to detect seasonal influenza virus infection, or an individual with a clinically compatible illness or who died of an unexplained acute respiratory illness, and who is considered to be epidemiologically linked to a probable or confirmed case.
A close contact is an individual who has cared for, lived with or had direct contact with respiratory secretions or body fluids of a probable or confirmed case of influenza A/H1N1. For probable cases, close contacts were followed at home and work. Contact tracing was coordinated by the Medical Officer of Health (community-based public health leader) and a team operating within the community. Close contacts with symptoms were isolated at home or in hospital depending on the severity of symptoms. Contacts were given a short sensitization session and fact sheets on hand hygiene, respiratory etiquette and proper cleaning methods of laundry and other household items.
Community restrictions
School and workplace closures
At the peak of the epidemic in Barbados, many primary (ages 5-11) and secondary schools (ages 11-18) reported absenteeism rates from schools ranged from as low as 9% to as high as 40%. Based on the latest available evidence, the Ministry of Health, in collaboration with Ministry of Education, decided not to close schools in hope of preventing further spread because the benefit of doing so was not sufficient enough to justify the social and economic consequences of such an action. There was still, however, some disruption within schools. At the start of the pandemic each school that was affected through infection by either students or teachers, was visited by public health officials to educate and allay fears of mass morbidity and mortality. This meant that classes were cancelled for approximately 1-2 hours in each case as fears were addressed. Public health officials also visited the workplaces of the first reported cases to conduct similar educational seminars, so some productivity would have been lost during that time. One school, however, reported high (75%) absenteeism among staff , which resulted in education officials making the decision to close the school to prevent issues of discipline and security from arising.
Cancellation of group events
The ‘Crop Over Festival’ is Barbados’ major cultural extra vaganza for the calendar year and is a significant source of revenue for the island. The festival is held from July to August each year and is characterized by social gatherings throughout the season, which may range from 100 to 30,000 persons. Given the available evidence, the decision was taken not to cancel any of the events associated with the festival, but ill persons were asked not to attend the gatherings. Patrons were asked to refrain from their usual custom of waving rags and using shared drink containers. The festival activities were used to educate the populace in the use of appropriate hand hygiene and respiratory etiquette. This education was done using calypso jingles that represent the signature musical genre of the festival, as well as through distribution of flyers along the highways as persons engaged in the festivities.
Pharmaceutical intervention methods
Pharmaceuticals – oseltamivir
The Barbados Drug Service was able to procure 49,000 courses of oseltamivir (Tamiflu) as part of pre-pandemic preparedness. A protocol was developed by the Ministry of Health to manage the distribution of Tamiflu in both the private and public sector. This protocol was first circulated in May 2009, and use was restricted to those with moderate to severe respiratory illness who met the case definition of a suspected case, which at that time included fever, cough and/or sore throat and a travel history to an affected area. As the disease became more widespread in Barbados, the case definition for a suspected case of H1N1 was modified to exclude the travel requirement, and Tamiflu usage was thus increased. As more information became available about the virus, the protocol was revised; in July 2009 those with mild respiratory illness who had certain specified chronic diseases and those with moderate to severe illness were eligible to receive Tamiflu. The drug was widely used throughout the outbreak and no cases of resistance were reported.
Pharmaceuticals – vaccine
Plans for procurement of 2009 H1N1 vaccine were made through the Revolving Fund of the Pan American Health Organization. A conference of the Sub-Regional Workshop for the Planning of Pandemic Vaccine Introduction was attended by Ministry of Health officials to develop a plan for the deployment of the vaccine within two to four weeks after its arrival on the island. The plan, which was based on a PAHO vaccination guide [13], identified health care workers, pregnant women, and persons over six months with underlying diseases as the main target groups for vaccination. The initial target was 50,000 doses based on estimations of prevalence of the diseases in the Barbadian population. Due to economic constraints and estimates of anticipated vaccine uptake, the actual number of doses acquired by the government was 20,000 doses at a cost of approximately USD 150,000. This cost includes only that of the actual vaccine and excludes the extra supplies and human resources that would be needed to administer the vaccine. The vaccination campaign began in February 2010. After four weeks, 39% of the estimated target group had been reached—51% of health care workers, 10% of pregnant women and 31% of persons who had been targeted with chronic disease. The vaccine campaign was extended for a further 6 months; 10,900 (54%) doses of the vaccine have been utilized.