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Evaluation of the Sexually Transmitted Infections (STI)
Surveillance System in Barbados
On site evaluation: July 9-13, 2012
Final Report: June 26, 2013
Evaluation Team and Counterparts
Dr. Mary L. Kamb, Division of STD Prevention, CDC
Dr. Hillard Weinstock, Division of STD Prevention, CDC
Dr. Paul Edwards, PAHO
Dr. Frances Smith, Clinical Medical Officer, Ministry of Health, Barbados
Dr. Dale Babb, Clinical Medical Officer, Ministry of Health, Barbados
Dr. Anton Best, Senior Medical Officer of Health(Communicable Diseases), HIV/AIDS Program,
Ministry of Health, Barbados
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Table of Contents Page
A. Executive Summary 4
B. Purpose and Objectives 5
B.1. Background 5
B.2. Evaluation Purpose and Objectives 6
C. Key Institutions Visited and Individuals Met 7
D. Methodology 8
D1. STI prevalence and supportive health infrastructure 9
D2. STI Services 10
E. Description of STI Management Systems and Sources of Data 11
E.1. Ministry of Health/Public Health Care System 11
E.1.1. Winston-Scott Polyclinic 12
E.1.2. Branford-Taitt Polyclinic 13
E.1.3 Public Health Laboratory 13
E.1.4. Lady Meade Reference Unit Laboratory 13
E.1.5. Leptospira Laboratory 14
E.1.6. Queen Elizabeth Hospital Laboratory 14
E.2. Private Sector 15
E.2.1. Meeting with Private Physicians 15
E.2.2 Private Laboratories 15
F. Evaluation Limitations 16
G. Findings, Conclusions and Recommendations 16
G.1.Review of Currently Available Data 17
G.2. Development of Case Definitions 17
G.3. Reporting 17
G.4. Quality Control 18
G.5. WHO Antenatal Surveillance Needs 19
G.6. Dissemination of Surveillance Data 20
H. Summary of Findings, Conclusions, and Recommendations (Table) 21
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Abbreviations used
AIDS Acquired Immune Deficiency Syndrome
AMR Antimicrobial resistance
ANC Antenatal clinic
ARV Anti-retroviral (drug)
BFPA Barbados Family Planning Association
CAREC Caribbean Epidemiology Centre
CD Communicable Disease
CDC Centers for Disease Control and Prevention
CHART Caribbean HIV/AIDS Regional Training Barbados
CMO Chief Medical Officer
CSR CAREC Surveillance Report
CT Chlamydia trachomatis
DSTDP Division of STD Prevention at CDC, Atlanta
EIA Enzyme immunoassay
EQA External quality assurance
GC Gonorrhea
GUD Genital Ulcer Disease
HAART Highly Active Anti-retroviral Treatment
HBV Hepatitis B Virus
HIV Human Immunodeficiency Virus
HPV Human papillomavirus
HSV Herpes Simplex Virus
HTLV Human T-lymphotropic virus
LRU Lady Meade Reference Unit
MSM Men who have sex with men
MTCT Mother-to-child transmission
MARPs Most-at-risk populations
MOH Ministry of Health
NAAT Nucleic acid amplification test
NGO Non-Governmental Organization
PAHO Pan American Health Organization
PCR Polymerase chain reaction
PID Pelvic inflammatory disease
PLWHA People living with HIV or AIDS
PMTCT Prevention of Mother-to-Child Transmission (of HIV)
PN Partner notification
QEH Queen Elizabeth Hospital
RPR Rapid Plasma Reagin
STD Sexually Transmitted Disease
STI Sexual Transmitted Infections
TOR Terms of Reference
TPPA/TPHA Treponema pallidum particle agglutination assay
VCT Voluntary Counselling and Testing
VDRL Venereal disease research laboratory test
VL Viral Load
WHO World Health Organization
WB World Bank
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A. EXECUTIVE SUMMARY
From July 9-13, 2012, an integrated team of external and Ministry of Health evaluators conducted an
evaluation of the surveillance and clinical (treatment) and program management of sexually transmitted
infections (STIs) in Barbados at the request of the Ministry of Health, Barbados. This report reflects the
team’s findings on the STI surveillance system. It accompanies a report on STI clinical and program
management.
The purpose of this evaluation is to assist Barbados in reviewing the existing surveillance systems for
STIs in Barbados and to make recommendations for the collection, reporting and analysis of data related
to STIs. Surveillance for congenital syphilis was a particular focus with its integration with perinatal
HIV surveillance to assist in the future evaluation of the Elimination Initiative.
The evaluation team consisted of senior public health personnel from the CDC/Division of STD
Prevention, PAHO in Trinidad and Tobago, HIV/AIDS Program in the Ministry of Health
(MOH),Barbados. The evaluation was based on interviews with key stakeholders of STI surveillance in
Barbados and key reporters, including public and private providers as well as public and private
laboratorians. The evaluation included a desk review of available reports, published literature, on-site
visits to several health facilities, and in-depth discussions with providers and other health officials.
At the end of the visit the members of the team held separate formal presentations with the Chief
Medical Officer (CMO) and with a large group of public and private stakeholders involved in STI
surveillance, discussing findings and possible next steps.
Key findings include:
• Although limited surveillance data are available, there is no formal STI surveillance system in
place nationwide
• Case definitions had not been published at time of evaluation. (They have since been published.)
• A strong public health system is in place, including a strong Ministry of Health and public health
workforce capacity.
• There is strong STI laboratory capacity, particularly in the public sector.
• The extent of STI burden is uncertain, with limited studies available on vulnerable populations
(adolescents, young women) or traditionally high risk populations.
• The Ministry of Health does not regularly receive information on STIs from the private sector
Country is well placed to evaluate emergence of antimicrobial resistant gonorrhoea, a current
global concern
• Per law minors (less than 18 years of age) require consent for care, which may make it difficult
to monitor disease in that population.
Several recommendations were made, but the following are most important:
1. Review data currently available to the Ministry of Health
• Syphilis serologies by sex, age group, pregnancy status, and clinic type
• Chlamydia by sex, age group and clinic type
• Gonorrhea by sex, age group and clinic type
2. Prioritize diseases for surveillance in the following order:
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• Congenital syphilis
• Adult syphilis
• Gonorrhea
• Chlamydia
In general, gonorrhea has more serious sequelae than chlamydia; given its lower
prevalence, it should also be easier to control, if not eliminate.
3 Develop surveillance case definitions for each STI under surveillance, publish, and
disseminate them to key stakeholders and providers.
4. Make syphilis in pregnancy notifiable by providers (by name)
5. Make gonorrhea and chlamydia notifiable by laboratories including information on sex, age,
and public/private status; these cases may remain anonymous
6. Make reactive syphilis serologies notifiable by laboratories using name or national ID
number to allow for MOH follow-up
7. Monitor gonorrhea resistance through antimicrobial susceptibility testing and link findings to
available epidemiologic/clinical data
8. Review all data on a regular (at least quarterly) basis
a. There should be routine follow-up on data problems and inconsistences
b. Follow-up on morbidity concerns based on findings from data
9. Develop and publish an annual surveillance report modeled on the HIV surveillance report;
these could be combined
10. Disseminate the annual surveillance report to key stakeholders, including public and private
providers, public and private laboratories, ministry of health officials
PURPOSE AND OBJECTIVES
B.1 Background
STIs are among the most common of all infectious disease categories, with global annual incidence
exceeded only by diarrheal diseases, malaria and lower respiratory infections. STIs are of great public
health concern not only because of their acute morbidity and the costs associated with health visits, but
because they pose potential for serious long term sequelae. The World Bank (WB) has estimated that,
excluding HIV, STIs and other reproductive tract infections (RTIs) account for 17% of outpatient health
care visits among reproductive-aged adults, in most nations ranking in the top five leading health issues
for which adults seek health care. Throughout the world STI burden is highest in adolescents and young
adults. STIs disproportionately affect women and infants who bear the burden of the most severe
complications including adverse pregnancy outcomes such as perinatal death and disability, infertility,
and reproductive cancers. STIs burden is greatest in countries that lack sufficient laboratory capacity to
effectively diagnose infections allowing prompt treatment and prevention of adverse outcomes.
One of the major issues affecting STI health care utilization, and thus detection of disease, is the social
stigma associated with these infections in virtually every society. As outlined in a 2007 World Bank
report, shame, stigmatization or both lead many affected individuals to seek treatment outside
established health care systems, with traditional healers, self-treatment using alternative or over-the-
counter remedies, or not seek treatment at all. In almost all nations, more STIs are treated in the private
than public health sector where STI management is reported to be more accessible, confidential and less
judgmental. However, private providers are also more likely to use unnecessary or inappropriate
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diagnostic tests (leading to higher costs), outdated or ineffective treatment regimens, and not treat sex
partners.
STI surveillance is critical for assessing the magnitude of the problem, trends over time, emergence of
outbreaks or new problems, development of prevention strategies, prioritization of resources, and
monitoring public health effects. There are several approaches to surveillance that can provide
complementary information. First, case-reporting provides a measure of new cases of STI or associated
syndromes over a specified time interval and is the most common surveillance activity, especially in
jurisdictions with functional reporting systems for notifiable infectious diseases. In industrialized
countries, gonorrhea, syphilis, and chlamydia are generally nationally reportable, with reports generated
by clinicians, laboratories, or both. In developing countries where national reporting is more difficult,
reporting from sentinel clinics can be useful. Second, prevalence monitoring can define the prevalence
of STI or related syndromes in defined populations undergoing routine assessment (e.g., screening or
diagnostic testing for infections, examination for syndromes) and can complement case-reporting in
assessing the burden of infection or disease. For example, in the U.S., while notifiable cases of
chlamydia have continually climbed as screening has increased, prevalence monitoring in STI and
family planning clinics has shown little change, indicating that the burden of infection is unlikely to be
rising. Third, sentinel surveillance generally refers to data collection from representative “sentinel
populations” for outcomes not routinely measured, such as antimicrobial resistance or infectious
etiology of various STI-related syndromes, and is often useful for generating broader guidance about
appropriate treatment regimens and national lists of essential medications. Fourth, population-based
surveys, involving collection of data such as prevalence of specific infections from persons considered
representative of the general population are difficult to perform but provide the best assessment of
population burden. In addition to these approaches for assessing morbidity, periodic surveillance of
sexual behaviors or health services can be useful in monitoring the need for or responses to educational
and health marketing efforts, and can also provide information on where prevention services are most
needed..
B.2 Evaluation Purpose and Objectives
The evaluation was a collaboration between the Pan American Health Association (PAHO), the U.S.
Centers for Disease Control & Prevention (CDC) and the Barbados Ministry of Health (MOH). The
purpose of the evaluation of STI surveillance in Barbados was to identify means of improving STI
surveillance so that through a better understanding of disease burden, improvements can be made for
improving the control of STIs.
The goals of this evaluation were to:
• undertake a review of existing surveillance for STIs in Barbados
• review STI laboratory services in the public and private sectors
• make recommendations for collection, reporting, and analysis of data related to STIs
Additionally, as CDC works closely with WHO on the global elimination of congenital syphilis and
PAHO on the Americas regional objective of dual elimination of MTCT of HIV and syphilis, the
evaluation looked carefully at Barbados’ congenital syphilis management and surveillance.
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C. KEY INSTITUTIONS VISITED AND INDIVIDUALS MET
Ministry of Health
The Honorable Donville O. Inniss Minister of Health, Barbados
Dr. Joy St. John Chief Medical Officer
Mr. Manasseh King Senior Administrative Officer
MOH HIV/AIDS Programme
Dr. Anton Best Senior Medical Officer of Health (CD), HIV/AIDS Programme
Dr. Frances Smith Clinical Medical Officer (STIs)
Dr. Dale Babb Clinical Medical Officer
Dr. Karen Springer National Epidemiologist
Dr. Elizabeth Ferdinand Senior Medical Officer of Health
Dr. Wendy Sealy National Training Coodinator, CHART
Ms. Shawna Crichlow Data Analyst, HIV/AIDS Programme
Ms. Shana Burrowes Strategic Information Officer, HIV/AIDS Programme
Queen Elizabeth Hospital (QEH) Laboratory
Dr. Delores Lewis Head of Pathology, consultant in Microbiology
Public Health Laboratory (PHL)
Mr. Edmund Blades Laboratory Manager
Ladymeade Reference Unit (LRU)
Ms. Kelly Carmichael-Simmons Laboratory Technologist
Mr. Hutson Forde Laboratory Technologist
Ms. Sheila Forde Community Health Sister
Ms. Fay Denny Community Health Sister
Leptospiriosis Laboratory
Dr. Marquita Gittens-St.Hilaire Head of Laboratory
Ms. Nicole Clark-Greenidge Laboratory Technician
Winston Scott Polyclinic
Dr. Natasha Grannum-Sobers Clinical Medical Officer (ANC)/Epidemiologist
Ms. Joan Brathwaite Senior Health Sister
Ms. Michelle Brathwaite Health Sister, Antenatal clinic/STI clinic
Mrs. Emeril Blackman Health Sister, Antenatal clinic/STI clinic
Mrs. Hazel Buckmire-Austin Health Sister, Antenatal clinic/STI clinic
Ms. Juliet Chandler Health Sister, Antenatal clinic/STI clinic
Mrs. Lavonne Patrick-Bacchus Health Sister, Antenatal clinic/STI clinic
Branford-Taitt Polyclinic
Dr.$Heather$Armstrong$$$$$$$$$$$$$$$$$$$$$$$$ Medical$Officer$for$Health$
Mrs.$Harewood$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ Health$Sister$
Private Sector
Dr. Vijaya Thani Private Practitioner, St.George
Dr. Tracey Archer Senior Medical Officer, Barbados Family Planning Association
Mr. Darcy Evans Head of Laboratory Services, Spectrol Labs
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Mr. Egbert Gibson Director, Barbados Reference Laboratory
PAHO
Ms. Thais Dos Santos Epidemiologist, PAHO Caribbean Office
Dr. Paul Edwards Lead on Health Information Systems, Advisor on Strategic
Information, Caribbean Office
CDC
Dr. Rachel Albalak CDC Director, Caribbean Regional Office (CRU)
Dr.. George Alemnji CDC Deputy Directory/Laboratory CRU
D. METHODOLOGY
The evaluation team consisted of senior technical staff from CDC, PAHO and the Barbados Ministry of
Health HIV/AIDS Programme. The CDC advisors from the Division of STD Prevention (DSTDP)
were medical epidemiologists with background on the clinical and programmatic management of STIs
who were experienced in developing and implementing STI surveillance and treatment guidelines. One
CDC technical member leads the CDC DSTDP Surveillance Team that oversees STI Surveillance in the
United States, receiving reports on lab-based and other STI surveillance measures from all U.S. states
and territories. The other leads the CDC DSTDP Global Activities, supporting WHO/PAHO in global
elimination of congenital syphilis including monitoring and evaluation of program progress, supporting
global GC antimicrobial resistance (AMR) surveillance, and supporting stronger global STI surveillance
systems. The PAHO advisor is located in the PHCO, Trinidad and Tobago, and leads Health
Information Systems and Strategic Information with special emphasis on strong health information
systems and data collection. He is also involved in supporting Caribbean countries in validating
elimination of congenital syphilis based on countries’ surveillance data. The Ministry of Health
technical staff included the lead for the HIV/AIDS Programme, two senior medical officers, the data
analyst, strategic information officer and community health sister involved in the HIV/STI Programme.
The methodology used was based on best practices used by WHO and CDC for evaluating public health
programs and surveillance systems with modifications to ensure relevance to Barbados. The evaluation
included meetings with the key Ministry of Health staff as well as those involved in STI surveillance,
clinical management and laboratory testing along with other non-government stakeholders (e.g.,
physicians working in private practice or non-governmental organizations involved in reproductive
health). Large meetings were held to allow interactive discussion with informants, and smaller meetings
were also done to allow more in-depth discussion about specific issues.
On-site visits were made to:
(1) Representative health facilities involved in STI management, including two polyclinics
providing primary health care, STI and antenatal services, and one large hospital (Queen
Elizabeth Hospital) that provides a large proportion of the island’s delivery services;
(2) All four MOH laboratories involved in STI testing
(3) Two of the largest private laboratories serving Barbados that provide STI testing for the
private sector.
At each clinic visit recent programmatic data related to STIs were examined to get a sense of service
utilization, completeness of data reporting, and quality assurance systems. The team held in-depth
discussions with key program staff from government health facilities (e.g., polyclinics) who were
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involved in partner notification and community outreach services, and in-depth interviews with private
physicians involved in STI care. With Ministry of Health colleagues, we reviewed the national STI
guidelines, surveillance guidelines for communicable diseases, data collection forms involving STI
services, including program and laboratory forms, and laboratory data collection systems around STI
testing. The CDC evaluators also visited one pharmacy.
Discussions and in-depth interviews used a free form format (non-structured), but the same general
surveillance topics were covered with all participants. Program data and lab forms were collected for
each of the programs and laboratories visited, with the exception of the private laboratories.
D.1 STI prevalence and supportive health infrastructure
The health systems profile of Barbados has been well described in multiple recent documents. Briefly,
Barbados is an independent democratic country in the Caribbean with a population estimated at 288,000
(2013) of whom 60% are aged 15-54 years (median age 37). The island occupies 166 square miles,
making it one of the most densely populated countries in the world. In 2008 total life expectancy at
birth was 74 years, with a female life expectancy of 77 years. Infant mortality rate is relatively low, and
has declined steadily from 14 per 1,000 live births in 1990-1995 to 11 per 1,000 during 2000-2005, with
a total fertility rate of 1.5 births per woman from 2000-2005 (Health Systems Profile, 2008).
The government of Barbados has focused efforts on education, poverty reduction, and health. With
literacy rates estimated at 98%, health services are provided to citizens free of charge through a well-
established health care system. A robust private health care system also exists. The public sector health
system is divided into eight health care divisions or catchments covered by eight polyclinics and four
satellite outpatient clinics under the Ministry of Health. Polyclinics provide a broad range of preventive,
curative and rehabilitative services including STI services and antenatal clinic services. Barbados has a
fairly large number of trained providers including physicians (general and specialized, including
Obstetrician/Gynecologists), nurses and pharmacists.
Nonetheless, HIV is a high profile disease, and through 2010, 3,426 cases have been identified, of whom
1,918 are still living. In 2010, 99.3% of women attending public (free-of-charge) antenatal clinics
(ANC) were tested for HIV, and positive women are treated with ARVs. The PMTCT program,
ongoing since 1995, is well documented and managed with follow up of all cases, and no case of
perinatal HIV transmission has been documented in Barbados since 2007. According to the PMTCT
guidelines, all pregnant women are offered HIV testing at their first antenatal visit, and per discussions
with providers, syphilis testing is offered in a similar fashion. Repeat testing for HIV occurs at 32 weeks
of pregnancy according to the guideline recommendations and is evidently being increasingly
performed. Those clients presenting to the QEH for delivery will have a rapid test done for HIV and a
sample drawn for a VDRL. Women with un-documented HIV (per guidelines) and syphilis tests (per
report) have these tests repeated post- partum. Based on ANC surveillance data, HIV prevalence among
pregnant women attending public ANC clinics is estimated at 0.96 % (2008). Coverage in the private
sector, though unknown, was anecdotally reported to be equally high by the private providers with
whom we spoke.
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D.2. STI Services
STI services are provided by physicians and nurses in the eight polyclinics using a presumptive
diagnosis approach based on symptoms and STI tests (HIV, CT and GC chlamydia PCR (urine), syphilis
VDRL and, if positive TPHA) to confirm the diagnosis. STI testing is done at a variety of laboratories
and results take about 1-2 weeks to return: GC culture and microscopy (Gram stain), as well as
microscopy for trichomonas (wet mount) are performed at the Public Health Laboratory (PHL) attached
to the Winston-Scott Polyclinic. Serology for HIV, hepatitis B, and HTLV-1 can be performed at Queen
Elizabeth Hospital (QEH) Laboratory. Urine PCR testing for gonorrhea and chlamydia are done at the
Ladymeade Reference Unit (LRU). Serologic testing for herpes simplex virus (HSV-2) and Darkfield
microscopy for treponemes can be performed at the Leptospira Laboratory.
In 2006, following a World Bank Report recommendation, a dedicated STI clinic was established at the
Winston Scott Polyclinic (WSPC), and a post for an STI Director was established to manage the clinic.
The STI Clinic is part of the MOH HIV/AIDS Program (the eight polyclinics lie under another branch of
the MOH). STI services are provided 5 days a week at the STI Clinic, which acts as both a clinic for
walk-in patients (self-referred) and a reference centre for public and private providers. There are 2
designated STI Clinic days (Tuesday and Friday) for screening and management of STI clients. On the
other days clients are seen for follow up visits, and there may also be referrals from the General
Practitioner (GP) clinic or Family Planning Clinics at the WSPC. In the absence of the STI physician,
clients are seen by the WSPC GP physicians or the physician responsible for the ANC clinic. Other
urgent cases can be accommodated for screening and management at the Queen Elizabeth Hospital
through the urgent care clinic, with referrals to WSPC STI Clinic for follow up.
Staffing at the STI clinic includes the STI Director, an STI physician, and other MOH clinicians and
nurses with specialized training on STIs. One nurse is assigned to the STI clinic and the position is
rotated every 3 months among nurses in the public health program. The STI Director’s responsibilities
include surveillance and management protocols of STIs, reviewing and updating treatment guidelines,
training in collaboration with CHART for healthcare workers in the public and private sector as well as
the daily management of clients with STIs.
Based on the PAHO Evaluation of Health Sector response to HIV and STIs, Barbados does about
12,000-14,000 syphilis tests annually, of which very few (68 of 13, 718, or 0.5%) are positive,
suggesting a low burden of syphilis in Barbados. It is likely these are mainly tests from ANC clinics,
but the report did not stratify on population (e.g., from STI clinic, polyclinics, screening populations,
ANC). According to written reports, many syphilis cases identified in testing are old, previously treated
cases with low titers; although our visit with the PHL suggested this was not always the case in ANC
clinics. Currently there is no syphilis registry utilized although there is an electronic database of syphilis
serologies at the PHL No information on syphilis cases is routinely reported to the MOH. However, all
treponemal confirmatory tests in Barbados are conducted by the PHL.
PCR testing for chlamydia and gonorrhea was introduced in 2004. In 2010, the LRU reported that 2,597
GC PCR tests were done, of which 2,142 were in women (likely primarily pregnant women). Positivity
data were not available (total or by population tested). A total of 3,840 GC cultures were done, of which
93 (2.4%) were positive. In 2010, a total of 3,067 chlamydia (CT) PCR tests were done, of which 529
(13.8%) were in men; most tests in women were reported to be from ANC clinics. CT positivity was
13.6% in men and 14.0% in women.
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By report, no babies with congenital syphilis have been recorded for seven years; however, there
appeared to be no standard practice for following pregnant women with positive syphilis tests or for
investigating stillbirths and neonatal deaths for syphilis. There is also no established case definition for
congenital syphilis. According to PAHO surveillance, one stillbirth in 2010 apparently occurred to a
VDRL positive mother, but this was not confirmed. A perinatal morbidity and mortality conference
conducted monthly at the QEH offers an opportunity to further assess for presence of syphilitic stillbirth
in Barbados, but is currently not attended by the MOH.
E. DESCRIPTION OF STI MANAGEMENT SYSTEMS AND SOURCES OF DATA
E.1. Ministry of Health/Public Health Care System
As noted, the public health sector including clinical and preventive medicine falls under the Ministry of
Health (MOH), with clinical services provided through 8 health-care catchments each served by one of 8
polyclinics located across the island. Health care is provided free of charge to all citizens or lawful
permanent residents of Barbados. Polyclinics are each staffed by several physicians and many more
public health nurses who are all part of the national MOH system, and provide an array of clinical and
preventive services ranging from primary care, antenatal services, geriatric services, urgent care, and
referrals. Those requiring referral to specialists or hospitalization are able to access the Queen Elizabeth
Hospital (QEH), a > 600 bed facility opened in 1964 that serves as the single public and tertiary referral
hospital for Barbados. The hospital has tertiary accident and emergency departments as well as urgent
care facilities; public medical and surgical wards; medical, surgical and neonatal intensive care units;
and a 13 bed dialysis unit providing daily services. The facility also has private rooms for patients at an
additional cost. Almost all infant deliveries in Barbados occur at the QEH.
In addition to QEH there are a small number of private hospitals in Barbados (Bayview was visited);
however these are fairly small (e.g., < 100 beds) and appear to serve low risk deliveries only. These
hospitals deliver approximately 10-20% of infants, with high risk pregnancies referred to QEH. There
are some private rooms located at the top floor of QEH. Women have the option of attending ANC care
at the public polyclinics which are free of charge (per report the majority of women choose this options),
or through private providers (for women able to pay out of pocket or with insurance that covers this) or a
combination of these. Per discussion, many people carry health insurance that can cover services at
private providers/facilities if needed; per discussions one reason that people would choose private
facilities is concern about privacy and confidentiality (e.g., with STI or HIV examinations). Wait times
do not appear to be an issue at the polyclinics per discussions and observations.
STI testing is carried out by public health nurses and physicians at the polyclinics, with nurses under the
supervision of physicians. STI diagnoses typically involve laboratory testing (e.g., urine NAATs tests
for chlamydia/gonorrhoea are available, as is gonorrhoea culture and syphilis serologic testing). Charted
diagnoses may be etiologic or syndromic. No standard clinical practice guidelines exist on STI
examinations, but, per report, nurses and physicians have received training within professional training
curricula and additional refresher training is also be available. All clients attending the STI Clinics are
offered an HIV test, VDRL for syphilis, hepatitis B and C testing, HSV1 and 2 testing, and PCR (using
urine) for CT and GC. The clients have the right to refuse these recommendations. The latter happens
very rarely as the uptake of testing is quite high. Those who opt out of testing usually return at a later
date for testing after they have had time to “prepare themselves”. Printed clinic charts include data for
some but not all tests and results; there is also an STD card.
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Regardless of whether patients present to polyclinics or private providers for HIV testing, all HIV
antibody testing is done at the QEH using a standard EIA, and none is done at private clinics or
laboratories. HIV results are provided to the data analyst of the HIV/STI programme for surveillance
purposes.
E.1.1 Winston-Scott Polyclinic
We visited the Winston Scott Polyclinic adjacent to the QEH and the LRU; the posted hours of
operation are 8:00am - to 10pm. An STI clinic (noted earlier) is open 2 days per week, Tuesdays and
Fridays and sees 25-30 patients per day. On other days, patients with STI symptoms are seen at the
General Practice clinic (about 10 to 12). Additionally, the clinic has ANC services two days per week,
seeing between 12 and 30 pregnant women per day. Some women come for examinations on other
(non-ANC) days.
Observations of the clinic log books indicated that demographic data as well as data on tests performed
and their results are collected; there is limited information on patient risk factors.
The nurses reported that male and female patients receive a full STI exam, but noted that women
“almost but not always” receive a speculum examination. The extent of the history was debatable. A
standard set of laboratory tests are taken for symptomatic patients or those seeking a check-up, including
syphilis serologies (VDRL), urine PCRs for GC/CT (men and women), and HIV. Additionally, for
patients with urethritis/cervicitis, Gram stain, wet mount (women) and GC cultures are obtained.
Extragenital testing (e.g., for those patients giving a history of oral or anal exposures) are generally not
done, nor are pH and whiff tests for women. All tests are sent to the LRU, PHL or QEH, depending on
the test. Patients are typically provided treatment based on their symptoms at the clinic visit, not at the
time when test results return (within 1-2 weeks, depending on the test).
Most clients are informed of their STI results when they return approximately 2 weeks after screening. If
the clients don’t return when they are advised to, they are then contacted by phone to come in for their
results. If the results are received by the clinic before the return date of the client, that person may also
be contacted by phone to come in sooner. The focus is on patients who were not fully treated at the time
of their initial visit. The client is never given an HIV result over the phone, whether it is negative or
positive.
Patients are provided prescriptions for treatment rather than drugs, and are able to fill the prescriptions
free of charge at the pharmacy located in the clinic (or at a cost at a private pharmacy). By nurse report,
patients are “always” offered condoms; no open bowl of condoms was noted. Nurses reported that
patients are asked to have their partners come in for treatment, but “most don’t come – they go to private
providers.” They also reported that in some cases patients might be given a prescription for their
partners for treatment (seemed a type of expedited partner treatment). Overall, the three nurses
providing data described three different strategies for partner notification – but regardless of approach,
most seem to be doing some type of partner management. Although data on partner notification (PN) are
collected in the log book, there were many blanks in the record.
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E.1.2 Branford-Taitt Polyclinic
We visited the Branford-Taitt polyclinic to talk with public health nurses and observe an antenatal clinic
(booking clinic for 1
st
pregnancy visit). The antenatal clinic is open 2 days per week, with one day set
aside for booking patients. STI patients are seen as part of the general medicine clinic (walk in); there
are no separate STI services.
We observed that though the same log books and data columns were available at this clinic, there was
variability in the way that data were collected. At Branford-Taitt, many data elements (columns) were
blank. Though copies of the yellow STD forms were available, the nurses noted that they were not
using it for STI cases.
Regarding antenatal screening, the nurses noted that HIV testing was offered to all pregnant women, and
syphilis testing was “usually” offered, but there were only a few syphilis cases identified each year. If
results return positive, they would typically call a mother or wait until the next appointment to treat the
woman. Treatment was penicillin, unless mothers were allergic, in which case, erythromycin was
provided. There was at least one and likely two cases of syphilis positive pregnant women who received
erythromycin last year, which, according to U.S. and PAHO case definitions for congenital syphilis,
would have resulted in at least one case of congenital syphilis. When a mother who tests positive for
syphilis in pregnancy is treated with erythromycin, the baby is also tested for syphilis according to QEH
protocol. No reports of infection in infants have been made.
E.1.3 Public Health Laboratory
We visited the national Public Health Laboratory and met with Laboratory Head, Mr. Edmund Blades,
and his team. The laboratory is open five days a week and has a number of staff, including specially
trained technologists. The laboratory conducts VDRLs for syphilis, confirmatory (treponemal) testing
for syphilis, gonorrhea cultures, gram stains, and wet mounts received from the polyclinics.
The PHL participates in EQA with a number of other laboratories in the region, Canada and the US
(including CDC for syphilis serologies). For syphilis, VDRL is done with titer and confirmatory TPPA.
It was stated that all confirmatory syphilis tests for the entire country are done by the PHL. Results are
provided only a few times a week in order to bundle testing and reduce costs. The PHL does not have
capacity to do darkfield testing for Treponema pallidum (but it was noted the Leptospira lab could
probably do these, if needed.) Relatively few gonorrhea cultures have been positive this year (39) and all
have been sensitive to the antibiotics tested, including penicillin and fluoroquinolones (using Kirby-
Bauer disk diffusion method). Cultures are sent from polyclinics using Amies media.
E. 1.4 Ladymeade Reference Unit Laboratory (LRU Lab)
A brief visit through the LRU labs, established in 2002, with Laboratory Technologists Mr. Hutson
Forde and Mrs. Kelly Carmichael-Simmons provided an overview of laboratory functions regarding
STIs and HIV. It was indicated that standard protocols on lab quality were being applied throughout.
CT/GC PCR testing for all polyclinics including the STI clinic at Winston-Scott, QEH, Barbados Family
Planning Association, and some private practitioners is offered by the LRU lab. Although HIV antibody
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testing is done at QEH (next door) using a standard EIA, the HIV results are provided to the LRU for
surveillance purposes and follow up.
The LRU uses Roche PCR on urine specimens from men and women; it was reported that there were
few problems with urine collection. Vaginal swabs are not tested. The LRU does CD4 and viral load
testing for all positive HIV patients identified at QEH; and, in fact, is the only laboratory able to do CD4
or viral load testing on the island; this testing is done for all providers as requested.
E.1.5 Leptospira Laboratoary
The team visited the national Leptospira Laboratory and met with the head of laboratory, Dr. Marquita
Gittens-St. Hillaire. She noted that the Leptospira laboratory was able to do the following STI tests:
HSV 1 and 2 testing, HTLV-1, hepatitis B and C. The Laboratory also has capacity for darkfield
microscopy and direct fluorescent antibody testing, although she cannot recall being asked to do these
tests for syphilis studies. During a tour of the laboratory, Dr. Gittens-St. Hillaire showed us that the
laboratory has existing PCR capacity although currently it does not do PCR testing for gonorrhoea or
chlamydia. She noted that the laboratory has plans to purchase a GenXpert (Cepheid system) in the
future with a planned amalgamation of the public health laboratories in a new facility (part of CDC
support to Barbados in its capacity as leading laboratory testing for the Eastern Caribbean region).
E.1.6 Queen Elizabeth Hospital Laboratory
The team visited the laboratories at the Queen Elizabeth Hospital (QEH) with Dr. Delores Lewis,
Consultant Microbiologist and head of the QEH laboratory. This unit provides laboratory services for
QEH and for the national blood banking system located in the hospital. All HIV antibody testing for the
country is done at QEH, while CD4 and HIV viral load tests are done at the LRU.
STI tests are primarily done at the LRU and PHL labs although QEH does some tests required for blood
screening (HIV, syphilis using TPPA, hepatitis B and C, and HTLV-1). For blood screening, if any of
the infections listed above return reactive, the donated unit is discarded.
The histology unit provides pathology for QEH. The technicians reported that they sometimes receive
specimens from stillborn infants (e.g., cord or placental specimens); but not routinely. They have the
capacity to do immunohistochemical tests assessing for the presence of T. pallidum.
Dr. Lewis also provided us a brief tour of the overall hospital including the Emergency Department,
Infectious Disease Wards, Medical, Surgical and Pediatric Intensive Care Units, Labor and Delivery
area, Post-partum and Pediatric Wards, Dialysis Unit and some other areas.
In an email, Dr. Cave noted that the Department of Obstetrics/Gynecology at QEH holds a monthly
meeting on stillbirths, and data are reported at the monthly Perinatal Mortality meeting and during an
annual Perinatal Data Review meeting. Public Health and Polyclinic presence was welcomed. However,
the team was not able to meet Dr. Cave in person or review the reports during this visit.
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E.2 Private Sector
Many patients seek STI services with private providers, and a large number of private providers exist in
Barbados.
E.2.1 Meeting with Private Physicians:
We were able to meet with Dr. Tracey Archer, Senior Medical Officer at the Barbados Family Planning
Association (BFPA) who described the functions of this non-governmental organization (NGO).
Additionally we were able to talk on several occasions with Dr. Vijava Thani, a private provider with
training in venereology, whose practice includes many STI patients, including young women. She
described her own private services and use of the private laboratories in Barbados.
Both physicians described STI management in private practice, including the laboratory diagnostics
available. Both noted specific concerns in a few areas: (1) high chlamydia prevalence in young women,
(2) generalized stigma around STI/HIV given the relatively small island population, and (3) lack of
STI/HIV and pregnancy prevention education among middle school aged children and teens (e.g., school
curricula still largely inadequate).
Both the Family Planning clinic and Dr. Thani’s private clinic see a number of sexually active
adolescents and young women under 25 years old, and routinely offer or provide chlamydia testing to
symptomatic women. It appeared that neither provided routine chlamydia testing to asymptomatic,
sexually active women but rather to those women at high risk. At the Family Planning clinic, CT testing
is done using NAATs on urine samples, with results provided by the LRU. Dr. Thani reported that
symptomatic women or those seeking a check-up had chlamydia testing, but asymptomatic women were
not routinely screened. Testing was typically done through a serum chlamydia test sent through a
private laboratory. Dr. Thani was able to provide data over past month suggesting that 20% (8 of 40
women < 25 years of age) had positive CT tests.
Asked specifically about antibiotic availability, they noted that, per law, antibiotics should only be
provided by prescription. We spoke about whether antibiotics are available over the counter (e.g.,
provided by pharmacies) in Barbados. In general, antibiotics should only be provided by prescription;
however, both physicians felt that there may be some pharmacies that do provide antibiotics for STIs.
(e.g., for men). Dr. Thani also noted that there are several alternative health providers in Barbados that
may be providing different types of STI and HIV treatment – she is unsure about numbers but feels that
at least several have large practices.
E.2.2 Private laboratories
The team visited Spectrol Laboratory, one of the large private laboratories providing STI testing, and
met with the head of the laboratory, Mr. Darcy Evans and his staff. Mr. Evans reported that Spectrol
Lab currently provides the following STI tests: chlamydia antibody testing, gonorrhea culture and
sensitivity, and RPR testing. Confirmatory syphilis serologies are sent to the Public Health Laboratory.
NAAT testing is not currently done.
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Mr. Evans noted that many private physicians (he would guess ~ 40) order STI tests, suggesting patients
with STIs are cared for by a large number of private providers. Currently the laboratory does not do
testing for patients without a request/prescription from a physician, but he believes that there is some
community interest in having walk-in testing sites (e.g., at private laboratories or physicians’ offices).
Spectrol Labs appeared to have a good relationship with the MOH and reported that it was willing and
able to provide a variety of data (e.g., on notifiable diseases) on request by the government, and would
be able to report names and other information (e.g., sex and age) if requested by the government.
The team also visited the Barbados Reference Laboratory, the largest private reference lab on the island,
located next to Bayview Hospital. This laboratory does testing for about 200 providers. The team met
with the Laboratory Director, Mr. Egbert Gibson and several of his staff. Mr. Gibson reported that the
laboratory is able to do RPR and treponemal confirmatory tests, Roche PCR for chlamydia and
gonorrhea (using swabs of urethral secretions for men and vaginal secretions for women), chlamydia
serology (most tests requested for chlamydia are from serum samples, HSV 1 and 2 serology using
Focus diagnostics, HSV PCR of ulcers using Focus diagnostics, and hepatitis antibody testing (also
serology). The lab does not do wet mounts. It is currently doing about 10 GC cultures per month. It is
doing about 15-20 RPR tests per day from private physicians (primarily antenatal tests). Most recently 2
of 373 RPRs were reactive. In distinction with Spectrol Laboratories, this laboratory does not report
results of syphilis serologies to the LRU (noting it is not notifiable). While describing a cordial
relationship with the government, the Laboratory Director also indicated that the Laboratory would not
be able to report any results unless the tests were clearly listed as notifiable in the disease lists.
Currently, the laboratory does send reports of notifiable diseases (along with name, age, and sex) to the
government. He believed that the laboratory would be unable to report names under most
circumstances, or other information such as sex and age, unless this was clearly documented in policies.
F. Evaluation Limitations
The evaluation was relatively brief (4 days), allowing visits to only 2 of the 8 polyclinics providing STI
and antenatal care in the public sector. We also were not able to visit clinics outside Bridgetown and
environs, and it is likely that some clinics perform differently than others. We were able to talk with
only two private physicians and visit 2 private laboratories. We were unable to observe STI management
in private clinics or in settings primarily serving women (e.g., family planning settings) or highly
vulnerable populations (e.g., sex workers and their partners, MSM). We were not able to observe how
surveillance is conducted for other infectious conditions in Barbados, but would recommend that
systems already in place for reporting other conditions also be used for reporting STIs in the future.
G. Findings/Conclusions and Recommendations
The results of this evaluation suggest that STI management and data collection in Barbados is
substantially more advanced than that in other countries in the region. The country has a highly
functioning public health system supported by an accessible polyclinic system, four public health
laboratories and a referral/general hospital. The public and private sector appear to work well together.
The population served by the polyclinics appears accessible to a broad diversity of people within the
population. However, while there are centralized data available and some electronic data systems are in
place, there is no apparent formal surveillance for STIs in Barbados. Surveillance case definitions for
STIs are not clearly defined. There is no routine review or dissemination of the largely public data that
are available and the burden of STIs in the private sector and among high risk populations (sex workers,
MSM, fishermen, tourists) is largely unknown.
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G.1. Review of Currently Available Data
A considerable amount of STI related data is already available. Particularly from the PHL and LRU,
reactive non-treponemal and treponemal test results are available as well as results from CT and GC
PCR tests. While these laboratories do not do STI testing for all of Barbados, it conducts a substantial
proportion of all STI testing (the exact proportion is not known). These available data should be
regularly reviewed by sex, age group (10-14, 15-19, 20-24, 25-29, etc ----- some age groups may need
to be combined due to small numbers), and clinic type (ANC, STI, private provider, etc). These regular
reviews may identify particular providers who are seeing a large share of the STI burden. They may also
identify providers who are not testing or screening for STIs as expected. Additionally, regular reviews of
logs at the polyclinics could be conducted relatively easily and provide valuable surveillance data even
prior to making STIs reportable. It would also be valuable to attend the monthly perinatal mortality
meetings at QEH. Susceptibility data on GC isolates are available from the PHL and should be reviewed
routinely. Evidence of decreased susceptibility or resistance in these isolates should be grounds for
wider and more systematic surveillance.
G. 2. Development of Case Definitions
Case definitions are obviously critical so that all stakeholders are clear on what is being monitored over
time. Even if there is not total agreement on how to define a case, stakeholders should at least know
what the definitions are and abide by them. A surveillance case definition does not have to equate to a
clinical definition. A clinician may decide to treat someone for syphilis (or another STI), for example,
even though it does not meet the surveillance case definition. Clinicians are more inclined to err on the
side of treatment since an error in not treating someone who should be treated generally has more severe
consequences than treating someone who does not need it. For public health surveillance, consistency is
more important; missing a case does not have the same repercussions. But inconsistencies in how a case
is defined over time or among providers may make monitoring trends impossible.
In establishing case definitions, Barbados could consider case definitions already published by other
nations with etiologic-based STD diagnosis (e.g., U.S., Canada, U.K, other European countries) and
modify them as necessary. Because of Barbados’ strong laboratories, case definitions should rely on
laboratory test results and not on syndromic conditions. For gonorrhea and chlamydia, a positive culture
or nucleic acid amplification test result should define a case. Chlamydia serologic tests are not useful for
diagnosing chlamydia and should not be used for clinical or surveillance purposes. For syphilis, reactive
nontreponemal (VDRL or RPR) and treponemal (e.g., TPPA) tests along with supportive history or
clinical findings should define a case.
G. 3. Reporting
As mentioned above, case reporting provides a measure of new cases of STI or associated syndromes
over a specified time interval and is the most common surveillance activity, especially in jurisdictions
with functional reporting systems for notifiable infectious diseases. In many high-income nations,
gonorrhea, syphilis, and chlamydia are generally nationally reportable. Because Barbados has sufficient
infrastructure in place for notifiable infectious diseases, we recommend that this system be expanded to
include syphilis, congenital syphilis, gonorrhea and chlamydia. The stigma attached to having an STI
and making STIs reportable conditions, particularly by name, could discourage STI testing and
diagnosis. However, the reporting of cases, particularly by name, has several potential benefits. It may
allow for the more rapid identification of outbreaks of infection and thus permit more timely
intervention by public health officials. Named reporting allows for follow-up of cases, particularly those
that may have dangerous sequelae like syphilis in pregnant women or congenital syphilis, to ensure
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appropriate treatment. Named reporting also allows surveillance staff to more easily remove duplicate
cases reported to the government; this can happen if more than one test is done during the same time
period or the same case is reported both by a provider and by a laboratory. Finally, by giving a more
accurate reflection of the true burden of STIs in the population, notifiable disease surveillance data,
when shared widely, can begin to reduce the stigma of infection.
Even in countries where reporting is well established, laboratories are generally better reporters than
providers. Where a case can be defined simply by a laboratory test as for chlamydia and gonorrhea,
making those conditions reportable by laboratories only may be sufficient. Where a condition depends
on both laboratory and clinical information as it does for congenital and adult syphilis, reports by both
laboratories and providers (e.g. clinics, hospitals as well as individual clinicians) are probably essential.
Depending on how much information associated with each case is required, laboratories may not be able
to report all the pertinent data because it is not available to them and follow-up with providers may be
necessary. It is generally a good principle to request only the minimum amount of information needed
with each case. That is the information the government will analyze or use to follow-up on the case. At
the outset, we would recommend collecting the age, sex, pregnancy status, and provider for each case. If
follow-up is anticipated, name and locating information should also be collected.
If possible, it is always preferable for cases to be reported in line-item fashion as a listing with each
name/number alongside its associated characteristics (sex, age, etc). In Barbados, where relatively few
reports are anticipated each month, mechanisms for reporting STIs should be coordinated with those for
other infectious diseases.
G. 4. Quality Control
Surveillance systems themselves need to be continually monitored for quality and completeness. This is
best done by regular review of the available data over time. Is the information associated with each case
complete? Is there a reduction in reported cases from specific providers or laboratories? Do some known
providers and laboratories not report at all? Of course, quality of the data cannot be completely
discerned by review of what is available. Regular (at least yearly) visits to large providers and
laboratories are necessary to ensure that reporting is being routinely done. When possible, a review of
log books or other files should be conducted and compared with what has been reported from that
provider or laboratory. These visits can be used as an opportunity not only to critique reporting
procedures, but to explain the importance of reporting and to discuss the data that the MOH has received
on STIs. If an annual Surveillance Report or summary of Barbados STI data is available, it should be
provided. Continual feedback of surveillance data is the best mechanism for encouraging better
reporting in the future.
With regard to monitoring of antimicrobial susceptibility patterns for Neisseria gonorrhoeae, conduct
routine (yearly) EQA (external quality assurance). Panels are available from WHO. Additionally, the
viability of GC isolates using Amies media should be assessed. This could be done by comparing the
number of viable isolates obtained from the Amies media with NAAT test results from the same
patients. While resistance to GC does not appear to be a problem currently, monitoring efforts are
limited: there are few viable isolates tested each year as well as a lack of quality control measures in
place.
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G. 5. WHO and PAHO initiatives on elimination of congenital syphilis: Antenatal surveillance
needs
WHO is recommending the following data be collected in its global efforts to monitor and eliminate
mother-to-child transmission (MTCT) of syphilis:
o The proportion of pregnant women receiving ANC care
o The proportion of ANC facilities providing routine syphilis screening
o Percentage of pregnant women at antenatal clinics receiving syphilis testing
§ At first ANC visit and ever (ideally by gestational age or trimester)
o Percentage of pregnant women at antenatal clinics testing seropositive for syphilis
o Percentage of women with positive serologies treated with at least one does of long
acting intramuscular Penicillin 2.4 million units as recommended.
Additional information about this is available in the WHO Report on “Methods for Surveillance and
Monitoring of Congenital Syphilis Elimination within Existing Systems” (2011) Available at:
http://whqlibdoc.who.int/publications/2011/9789241503020_eng.pdf.
These primarily programmatic data would, ideally, be collected as part of existing routine programmatic
data collection, and ideally linked to PMTCT of HIV and other MCH programs. WHO has
recommended programmatic targets to achieve elimination of:
- > 85% pregnant women attending antenatal clinics
- > 90% of first antenatal care attendees aged 15-24 years screened for syphilis
- > 95% of syphilis seropositive women adequately treated
- All (100%) infants born to women testing positive for syphilis treated with at least one
dose of benzathine penicillin
These are reported in the WHO report (2007) “The Global Elimination of Congenital Syphilis: Rationale
and Strategy for Action” (2007), Appendix 3, available at
http://www.who.int/reproductivehealth/publications/rtis/9789241595858/en/
Most of these data could be obtained through reviews of logs or medical records at all ANC clinics.
Determining the proportion of pregnant women receiving ANC care is more challenging but reviewing
delivery records for a defined period of time at all hospitals could provide this information. It might also
be useful to calculate the number of patients obtaining care at ANC clinics in one year as a minimum
estimate.
Anticipating the global elimination, PAHO has supported integrated programs for preventing MTCT of
HIV and syphilis, and in 2010 the Directing Council approved the Strategy and Plan of Action for the
dual “Elimination of Mother-to-Child Transmission of HIV and Congenital Syphilis in the Americas by
2015”also referred to as “HIV and Syphilis-Free Generations.” PAHO has identified a larger set of
process and impact indicators regarding both perinatal HIV and syphilis, as well as means of calculating
them, that can be found online at:
http://new.paho.org/hq/index.php?option=com_content&view=article&id=7264%3Aelimination-of-
mother-to-child-transmission-of-hiv-and-congenital-syphilis&catid=4679%3Afchhiv-
topics&Itemid=39600&lang=en
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PAHO’s overarching indicator for elimination of congenital syphilis is:
- Congenital syphilis cases < 0.5 per 1,000 live births plus stillbirths
Achieving elimination assumes (i) adequate records supporting completeness of congenital syphilis
surveillance data, such as the programmatic data recommended to be collected by WHO, and (ii)
adequate national or representative stillbirth surveillance that documents mother’s syphilis serostatus.
G. 6. Dissemination of Surveillance Data
Summarizing and disseminating the data available for key stakeholders, policy makers, and reporters
(providers of the data ---- laboratories, hospitals, clinics, large private providers) is a critical part of
conducting surveillance. This provides feedback to major reporters (and, thus, encourages more and,
perhaps, better reporting) and informs the public and policy leaders about the burden of disease. Where
data are limited or incomplete, that should be acknowledged and caution should be urged in the data’s
interpretation. Explaining the limitations of the data is important when justifying the need for better or
more complete reporting and requiring more information for certain conditions.
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H. SUMMARY OF FINDINGS/CONCLUSIONS AND RECOMMENDATIONS
Area
Findings/Conclusions for STI
surveillance
Recommendations for STI surveillance
General
Strong public health infrastructure,
including trained and motivated
personnel and laboratory capacity,
indicates Barbados is poised to be a
regional leader in STI as well as HIV
prevention/control
No formal surveillance system for
STIs is currently in place.
Little is known about STIs in the
private sector since STIs are not
reportable conditions and positive
laboratory tests for STIs are not
reportable.
Available surveillance data are
not routinely reviewed and
disseminated.
Resistant gonorrhea does not
appear to be a problem in
Barbados, but this assessment is
based on very few isolates tested
each year and no external quality
assurance program for the
susceptibility testing that does
occur.
Prioritize diseases for surveillance. Consider
prioritizing congenital syphilis first, then adult
syphilis with particular attention to syphilis in
pregnant women, gonorrhea, and chlamydia.
Diseases under
surveillance
No STIs, including congenital
syphilis, are currently under
surveillance.
Make congenital syphilis and syphilis in
pregnancy notifiable by providers (by name).
Make gonorrhoea and chlamydia notifiable by
laboratories.
Make reactive syphilis serologies notifiable by
laboratories (using name or national ID number
to allow for MOH follow-up).
Attend monthly Perinatal Mortality meetings or
Perinatal data review meetings at QEH.
Monitor gonorrhoea resistance through
antimicrobial susceptibility testing of isolates
received; if evidence of resistance occurs, there
may be a need for wider and more systematic
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collection of isolates for susceptibility testing.
Case definitions
Case definitions for STIs were
not established and published at
time of evaluation. National
guidelines do not specify
appropriate tests to use for
diagnosis of specific STIs. For
example, chlamydia serology
appeared to be regularly used to
diagnosis chlamydia even though
it has very poor specificity.
Develop case definitions for STIs under
surveillance using definitions already
established in other developed countries with
strong laboratory diagnostics as examples.
Publish the case definitions so they can be used
and applied by all potential disease reporters.
Data reporting
and analysis
At the national level, data
analysis is not done routinely and
therefore not utilized for
monitoring and evaluation,
planning or for policy decision
making.
Review available data on regular basis (at least
quarterly):
Syphilis serologies by sex, age group,
pregnancy status, and clinic type
Gonorrhea cases by sex, age group, and clinic
type
Chlamydia by sex, age group, and clinic type
Prevalence of Neisseria gonorrhoeae resistance
by antibiotic tested
Communication,
data
dissemination
and feedback
There is no current report of STI
disease burden in Barbados.
.
There were few visits to the
reporting sites conducted by the
national unit at Ministry of
Health.
Develop and publish an annual STI surveillance
report modelled on the HIV surveillance report
(preferably combined with it). The report
should contain tables and figures from analyses
of available STI data. It should be widely
available and shared with major laboratories,
clinics, and other major disease reporters.
Follow-up on data problems and inconsistences
based on quarterly data reviews.
Follow-up on morbidity concerns based on
quarterly data reviews.
Follow-up can be done in writing, by phone,
and through site visits as appropriate.
Visit major laboratories, large clinics, and other
major reporters on a regular basis even when
problems are not identified.
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Laboratory
Laboratory capacity is excellent.
Some electronic data systems are
already in place (for example,
syphilis serology test results at
the PHL).
Data generated from laboratory
testing are not routinely analysed
and therefore not fully utilized.
There is no established
mechanism for data
communication to the Ministry of
Health and reporting sites.
There are qualified and motivated
laboratory technologists involved
with communicable diseases
testing.
Neisseria gonorrhoeae isolates
are transported for susceptibility
testing using Amies media and
tested Kirby Bauer (disk
diffusion) methods.
Very few isolates are tested each
year for susceptibility and no
resistance (to any antibiotic) is
being identified.
A formal mechanism for communicating
reportable laboratory data to the Ministry of
Health should be documented and implemented.
Where electronic systems or logs currently
exist, regular reports could be generated and
reviewed both for quality of data and morbidity
concerns.
Conduct routine EQA (external quality
assurance) of gonorrhea susceptibility results.
Panels are available from WHO.
Evaluate viability of isolates using Amies
media. Results from culture could be compared
with NAAT test results available from same
patients.
Special studies
to inform
surveillance
Currently, no work is being done
to identify groups at particularly
high risk of STI.
Include STI evaluation in Biological and
Behavioral survey among men who have sex
with men. Consider urethral and extra genital
nucleic acid amplification testing for chlamydia
and gonorrhoea; serologic testing for syphilis,
HBV, and HSV 1 and 2. Arrange for treatment
of MSM with positive results.
Conduct periodic behavioural and biologic
surveys of potentially high risk groups (for
example, commercial sex workers, miner,
school age children).
Explore the role of tourism in disease
transmission.
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Examine feasibility of syphilitic stillbirth
surveillance.
.
