EPIDEMIOLOGICAL SURVEILLANCE AND 538-0027pdf.usaid.gov/pdf_docs/PDAAX719.pdf · The Epidemiological Surveillance and Training Project Agreement ... strategy of improving the cost

EPIDEMIOLOGICAL SURVEILLANCE AND TRAINING 538-0027 Project Assistance Completion Report

I Background aid Current Project Status

The major medical and public health advances of the past 100 years resulting in an improved quality of life and prolonged life span in developed nations have beer due in large part to decreases in morbidity and mortality from communicable (infectious) diseases Similarly the lower predicted life span and greater disease morbidity seen in the developing world are the result of the continued heavy toll of such diseases While polio typhoid tetanus childhood gastroenteritis and dengue are rare and sporadic diseases in North America they ha even very recently been common and devastating illnesses in the West Indies

The key to prevention and control of infectious diseases is approaching them as public health problems rather than primarily one-on-one in clinical settings Effective epidemiology programs run by knowledgeable staff are critical to ensurtig this approach is used Prior to this project however most of these governments were not able to support any meaningful epidemiology work Limitation in both laboratory facilities and manpower skills severely hampered efforts at the national level

The need both for upgrading the national programs and establishing a regional institution to provide the more sophisticated and costly services beyond the reach of regional governments was recognied by the Ministers Responsible for Health in the Commonwealth Caribbean in 1974 The Caribbean Epidemiology Centre (CAREC) was established as a PkH) collaborating center in 1975 in response to this need CAREC received initilt developmental assistance from the Centers for Disease Control in Atlanta from the period 1975-1978 This CDC grant helped to establish the Centre however assistance was still required to strengthen the institution (including bringing on mote West Indian talent to the staff) and to enable CAREC to reach out to fledgling national epidemiology programs

The Epidemiological Surveillance and Training Project Agreement between the Regional Development OfficeCaribbean and the Pan American Ibalth Organization was signed on May 23 1979 The project had three overall objectives (I) to assist CAREC Member Countries (CMCs) in disease surveillance and training activities (2) to improve the accuracy and efficiency of CMC diagnosis and surveillance of communicable disease and (3) to further develop West Indian middle management at CAREC The original project assistance complecion date of September 30 1980 was extended six times over the course of the project the project ended on June 30 1987 All commodities procured tirough the project have been provided a list is appended to this report A total of $25 million was obligated for this project

I Summary of Project Inputs and Accomplishments

The original project grant igreement laid out several institutional and programmatic strengthening activities to be undertaken (1) establishing a training unit at CAREC (2) providing training courses workshops and individual on-the-bench traireships to the 19 Cs (3) procuring certain

-2shy

laboratory equipment and supplies for CAREC and the CNICs and (4)expanding and diversifying the production and dissemination of educational materials and (5)establishing a data processing center at CAREC In addition to these broad directives the grant identified two programmatic areas to receive attention improving the cold chain distribution of immunizations to CMCs and undertaking a zoonoses surveillance study

A mid-term evaluation of the project completed in early 1981 indicated that CAREC was on schedule in providing training to health personnel and in building up its core capabilities to produce technical materials for health training in the region Major recommendations for CAREC by the evaluation team included intensifying surveillance and EPI activities improving evaluation procedures of training programs attemptiklg to tailor training more to specific country needs and including nurses in surveillance training Recognizing that the improved national epidemiology programs were in many cases still ependent on one individual at the country-level the position of deputy epidemiologist was introduced to the region The evaluation team applauded this effort but noted the need to provide 3 supportive career structure for such individuals

In 1983 the implementation plan of the project was expanded to provide support for the introduction of basic epidemiological components into tOe regions nursing curricula and the design and introduction of a program on sexually-transmitted disease This amendment also reflected discussions between CAREC and USAID to begin to wean the Centre off IJSAID support by including covenants which sought to transfer funding for key CAREC positions from the grant o CARECs core budget Training and siu eillance programs for improving the haniling storage arid transportation of f )d were introduced to the project scope of 4ork in 1)81

A final evaluation of the project was conducted in February 198S rhe evaluation team reported that training had been provided to over 3400 course participants (representing some repeated attendance) including national epidemiologists laboratory directors statisticians public health nurses public health inspectors laboratory technicians medical students hoteliers food industry personnel and others It noted that CARECs capacity to produce appropriate training materials had greatly increased during the project and that a significant improvement to both the surveillance and laboratory capabilities in the CMCs had been achieved The addition of new staff and the replacement of expatriate staff by qualified West Indians was also reported

Khile the evaluators noted that CAREC had completed nearly all of the tasks outlined in its scope of work it further cautioned that the constant threat of diseases such as dengue malaria polio and gastroenteritis and the emergency health problems of motor vehicle injuries chronic disease and occupationalenvironmental hazards nean that there will he a continued need for a regional epidemiological institution and one that is capable of a4justing to new needs while continuing to support existing control and prevention efforts Based on the recommendations of this evaluation team the project was extended to June 30 1987 and funding was provided for two new programmatic areas (nosocomial infection and traffic epidemiology) As this work progressed in August 1986 RObC agreed to collaborate with the National Institute of Occwpational Safety and Health by financing the start-up costs for a CAREC occupational safety and health program rhus during the last two years of project funJing while CAREC improved on the skills

-3shy

developed and funded earlier in the project (includi g conducting national surveillance workshops on-the-bench attachments and providing technical assistance as needed to C4Cs in the identification and surveillance of communicable disease outbreaks) the grant was funding only three activities nosocomial infection and control traffic injuries epidemiology and occupational safety and health Given that the project had been evaluated twice already the decision was taken not to conduct a final evaluation of the project In lieu of u final evaluation the three outstanding programs are reviewed more carefully here

NOSOCOMIUL INFECTION (NI)

The nosocomial infection program was initiated primarily as a health management demonstration project ie to illustrate how improving hospital hygenic procedures can result in lower operating costs for the institution expressed by a reduction in the length of patient stays inhospital As such the program 4as a critical component of the overall RDOC health sector strategy of improving the cost effectiveness of health care services in the region

The NI program began with the implementation of prevalence or incidence studies in three CNIC hospitals to identify the frequency of infection by type of service and the etiologic agent These studies were followed by tile development of procedures and protocols to reduce the incidence of such infections communicated through country-based workshops with newly-named nosocomial infection control teams Prevalorce studies complete] in Jamaica Antigua and Trinidad suggestel that the NI ite varied from $ to lpercent of the patients admitted Poor documentatioi of infections by hospital staff prevented comprehensive analysis of the Lta however it was estimated that each infection cost the hospital between JS$1500 to $3150 in extended hospital turati-n (ie hotel) costs

Accomplishments Over the course of this two-year activity NI programs were establishet in 10 04Cs (Grenada St Vincent St Lucia Dominica Antigua St ChristopherNevis amaica Guyana Suriname and Trinidad) and infection control nurses were identified and trained in these countries as well as inBarbados and the Bahamas The programs instituted in each country have varied according to the interest time and ability of NI control team leaders to implement the programs however successful interventions have included improvements to (1)hand-washing facilities and requirements (2)containment and transport of soiled and contaminated linen (3) the care and use of thermometers catheters and intravenous therapy (4) floor cleaning (wet mopping rather than just sweeping) (5)isolation of Infectious patients and (6) the use of antibiotics

N1 Committees usually comprised of the hospital matron chief medical officer medical supervisor hospital administrator ind the infection control officer were organized to discuss proposed interventions and the means of introducing them to the worksettinR most effectively Training and technical assistance were provided to nurses orderlies maids and where possible physici-ns W e to the late start in Implementing many of these Interventions the follow-up surveys originally anticipated to be conducted were dropped from the workplan

-4-

The program was not originally designed to have an AIDS component however due to the nature of this activity the CAREC NI program coordinator (a nurse epidemiologist) did include educating hospital workers on the management of AIDS patients and means of preventing the spread of this infectious disease in her training activities The topic was of particular concern to hospital maintenance and cleaning crews who were reluctant to clean or maintain rooms with AIDS patients

Lessons Learned While the NI program coordinator reprts that the hygenic interventions intrcduced in this program have been contributing to a reduction in the rates of nosocomial infection in the absence of follow-up prevalence studies this observation remains a qualitative and somewhat subjective one The program can offer two important development lessons however The first is that improvements to health care systems to the region do not necessarily involve large capital- or technology-intensive infusions of development assistance The entire budget for this two year activity covering 12 countries was less than $300000 but the simple relatively inexpensive hygenic improvements to haniling patients hospital equipment and supplies and to cleaning hospital quarters shoulJ result in significant enhancement to the delivery of health services in the Caribbean The second is that the neel to focus on cost containment (ie length of hospital stays) does not have to be at the expense of delivery of quality care but can as in this case result in improve] health care delivery

[he two most potentiilly critical constraints to the effective adoption and continuation of the nosocomial infection prngr3ms in the region are the aversion of cleaning and maintenance crews to ai)pting new behaviors and the scarcity of NI staff time to ensure that new protocols are strictly maintained On a positive note the CAREC NI program c~oriinator position has been retained by CAREC and follow-up monitoring and motLvation activities are being implemented on a regular basis This follow-on work is being facilitated by the regionally-adopted Nosocomial Infection Control Manual and the improved regional reporting system for nosocomial infection both of which were products of this grant activity

TRAFFIC INJURIES (rI)

rhis activity was designed to assist governments in reviewing the costs impacts and social services associated with traffic injuries in CMCs The intent of the program was to arrive at a better understanding of the epidemiology of traffic injuries eg causes settings injuries sustained etc so that interventions might be introduced to reduce the likelihood of such events and improve the quality of services provided to accident victims

The objectives were to be achieved through (1) analyses of the traffic control procedures and recent accident histories of each country followed by (2)country-level workshops which would facilitte examination of these issues by the various relevant publics (police emergency medico technicians medical officers traffic safety boards tisaster coordinators taxi driver representatives legal experts) and (3) the design and introduction of programs to rectify the most critical problems in injury control

Accomplishmnts This activity has not enjoyed the same level of success as other CAREC program Legislation was collected and analyzed from each of the 19 CMCs and model guidelines for the assessment of drivers of private heavy goods and public service vehicles were prepared by CjAEC for review in country workshops

As a preface to the country workshops epidemiological studies were tudertaken in St Lucia Dominica and Suriname these studies found that (1) males suffered more injuries than females by a 31 ratio (2) injuries sustained-^ in accidents were mainly intracranial (and usually fatal) for passengers and drivers and involved fractures to limbs and ribs for pedestrians (3) minibuses and goods vehicles were involved i lore accidents than personal or public service vehicles and (4)most collisions resulting in injuries occurred on the apparently better roads The St Lucia study found that motor vehicle accidents resulted in average hospital stays of 27 days with tempor3ry Jisability of 72 days At an average cost of EC$4400 in public health services rhe total cost from accidents to the health care service in St Lucia in 1985 was EC$308000 he results of these studies were discussed at the country workshops inSt Lucia Dominica and Suriname and used to develop a composite fictional case study for the other country workshops

A total of 10 intersectoral workshops were held over the course of this two-year activity as opposed to the 19 originally planned At these meetings countries frequently identified tne lack of data for comparison and monitoring of traffic injiries as a constraint to better understanding the problem however autnorities were alost universally rel witant to interfere with existing data collection systems )ther common prThlems included the absence of a functioning group to coorlinate and monitor motor vehicle prevention activities hazardous road conditions inadeltuate vehicle inspection facilities resulting in licensing of defective vehicles and outdated legislation especially with respect to use of se3t belts driving under the influence of drugs carriage of passengers and detection of speed limit offenders

While the workshops 6iere successful in raising awareness of the circumstances and conditions which promote or inhibit traffic accidents with the exception of two copintries (St Lucia and Montserrat) this interest did not translate to a willingness to move workshop recommendations to Cabinet for consideration In St lucia the Cabinet approved most of the workshop recommendations with tte exception of the formation of a National Traffic Safety Committee

Lessons Learned This ictivity was designed as a result of a 1484 Preventin and Care of M tor Vehicle Injuries in the Caribbean workshop at which it was recurmmended that rARFC coordinate epidemiologic research and training Activities related to the prevention of motor vehicle injuries Despite their best efforts over two years the program has had limited success at generating sustainable interest by governments in tackling this critical problem The exact reasons for this limited success are unknown although several hypotheses have been pose] including the economic costs of implementing components of a traffic Injuries rediction program behind the scenes lobbying by alcohol producers automobile dealers and employee (eg minibus) associations and a possible continuing lack of appreciation of the costs to society of traffic injuries

-6-

One of the strongest hypotheses for the lukewarm response to this effort however relates to the degree of intersectoral cooperation and participation required to implement a traffic safety program and the difficulties in ensuring that collaboration In the absence of a clearly mandated body--a National Traffic Safety Commissions inthis case--sustaining interest in and pat ticip3tion by each of the relevant Ministries has been difficult to achieve The lesson for future programs is that development efforts which require nulti-sectoral cooperation should only be attempted when there is broad-based political Will and a coordinating body (eg inter-agency committee) for ensuring collaboration by all parties

OCCUPATIONAL SAFErY AND IELTh tOSI)

The dual emphases on agricultural and industrial development in the Caribbean mean workers are prone to i wide variety of occupational hazards Agricultural workers Face several dangers in the workplace including exposure to chemicals especially posticides respiratory diseases from exposure to organic dusts such as flax cotton and cocoa work related injuries and long term disabilities related to excessive noise Workers inallied industries such as quarrying constriction manufacturing and food processing face danigers from exposure to industrial chemicals 13iiqerous poorly maintained equipment inadequate ventilition an] lightirn dad excessive noise from machinery

lthough their teconomjs ire tindergoing rapid lange occupational health laws in Cirib)ean countries have not kept up the -ace These laws are ge-lerally outlated md Io iot provitie useful or reasonaLe standards for governing conditions i1 the workplace nor ire there sutficient numbers of trained personnel to eassure that the laws wich do exist are honcred

ro address the viried and growing problems eminating from hazarls in the workplace the projeot provided limited assistance (1120000) to assist CAREC in the start-up of OSH programming for selectel iistern Caribhean countries Collaborating with the National Institute of 3ccupatioral Safety and Health (NIOSI) in the United States CAREC was able to secure the srvices of a trained medical epidemiologist on a two-year contract Grant funding was provided to undertake risk assessments in four countries to develop a model monitoring and control program for occupational healL and to conduct regional training of environmental health and labor inspectors Follow-up technical assistance and training to other Eastrn Caribbean countries the development of audio visual materials and a resource library and procurement of environmental testing equipment were to be undertaken outside of the grant after its expiration

Accomplishments he Epidemiological Surveil I ince and rrainitg Project provided stirt-ip assistance to tnis on-iolnR effort During the perioI the epidmiologizst was able to conduct risk assessmenti of occupational harls in St Lucia Dominica St Christpher and Nevis and GredaThe highiights of these isiessments were provi+kd in a two-dAy Deeting of health ministry representatives from the foir islands which took plae in St L-c1a in March 1987 pioduct of the meeting tas the design1 of currlcultA for i tao-week trainiig course iell it rrlnii d in June the course attended by 19 environmental helth officers iabor inspectors and national Insurance inspectors from St Lucii St ChriitopherNevis D~minici Grenada and

-7-

Trinidad provided practical training in the recognition and correction of couuon occupational hazards At the end of the course participants developed model programs for collaborative activities in occupational health surveillance that could be implemented upon return to their countries

Given the nasrent stage of this activity at the close of the grant it is not possible to comment oa further accomplishments or lessons which might be learned from this program

[II Development Impact

Wuring the eight years that RDOC provided assistance to the Caribbean Epidemiology Centre the Mission has had 3 front row seat from which to watch this institution develop into a first-rate service organiation in and for the Ciribbean The instittion has developed not only technical expertise )it has earned the respect of those it seeks to serve and tnose dho provide financial support to it

T[e function of RDOCs assistance was to assist rAREC in broadening its ireas of expertisc which once estahlishe were the responsibility of the Centre to maintain rhis strategy has been successful as can be implied from Director Peter Dkizorvs transmittal letter for their project completion report

In this letter I iotil] [also] i e to ref to other ictivities which ire i tip of pre-vious ictivi -s funded by the Jrant

I SurveillInce And Training - general

rhe CLentre continues to provide support to national programs for levelopment of national capacity for Jisease surveillance including epidemic investigation For exanple on July 23 1 personally participated in a surveillince iorkshop for Parish staff in Ja mica the forms and investigation guiJos developed tunder the project are in general use throughout the Caribbean and indeed we have had to reprint these items Stany of the deputy epidemiologists trzaned by the program ire till in place and are now contributing to t1e surveillance for AIV Infections and AIDS ur t-raining materials are in use by nationals for their In-service programs For exampc especially during 1986 nd 1987 there has beei a renewed demand for the section of the Epidemiology tinual - Post Disaster Surve ilInce 4e contie to distribute the Sr) anual ind the importance of the investuent in fri) training has been enhanced by the sexual transmissiv problem of MiV There ire for xample sevfril surveys im in pr)gres of protitutes arid iigh risk heterosexualis for l V wiic-i also includts i survey -f othersris

t the rftqiuo-t of the (AILC Scilntlfic Advisury Committee CmC is nfrtaklng i -irvey of the tsats of microhiologicil services Ir the 19 member c(xntries In iddition CIJliC is also reivin l ifnity precitit itsi in thesc IiboratorilI

-8-

We are endeavoring to obtain funds for a workshop for National Epidemiologists inOctober 1987 and for those responsible for HIVAIDS information to the public in 1988 CAREC has obtained funds from iHO Special Program on AIDS to recruit a Media Office a 4edical Epidemiologist and a Laboratory Technician specializing inHIV testing rhe technician isalready appointed and iscontinuing the tradition of on-the-bench training for n3tional staff Tie Media Officer will be selected during the First two weeks of August and the Medical Epidemiologist is teing appointed through our Washington Office and may be aboarJ by October

2 Food Safety

The Visual Aids and Print inaterials developed from the Grant are inconstant deman-t We continue to provide technical advice on Food Safety to the countries Of this activity it is safe to state that not one month passes without at least one request for assistance

3 Staffing

ithough we were iot ible to funI the position of Training Officec after the project funds ended we have as noted above now obtained Finds ftr i Media 9fficer ho will no Ioijbt enhance our resources for the prodiction 9)f training materiil-

the Nurse Epide nioloist Sherlyn ionteil has n absorbed into our regular core budget so is mentioned in th specific Nosocomial Report she can continue t- provide technial guidance

Indeed I have obtainel the concurrence of the CAREC Science Uvisory Committee md Council for her to o on one years Study Leave from either October 1987 )r January 1988 to get her 4asters in Public ifeilth with major subject Epil~mioloqy

rhe Data Entry Officer Judy Dyer has txen absorbed into the core budget

Dr Richard Keenlyside will he tvailible for at least another two yeari to continue the development of natioal Occupatiml Health Prograims in the Caribbean

In addition to the information iii)ilorys report it was noted In the Directors Report for 1)80 that ii 148) 3lone over 93 participants ittended train ing prograiim organtd by (RIT tin isease surveillaince laboratory technology statistics in toe tud )f cific liiesases ind their ctusative igent Altho gh (Ws have over tnr last fCw ejrs founi it fiifficlt to retmit their total quot ii to siupport tbe (entres activitir-s I) of the 1) countries did make some contribiton In 1J8f) [ie Centres grantifinsiip

caoabllities hiiv inctieaest owver to make up te shortfall

-9-

The Summary of 1986 Activities attached to this Project Close Out Report highlights further activities initiated under the grant and maintained by tOe Centre

IVRecommend3tions for Continuing nitoring and Post-Project Input

With the close of the Epidemiological Surveillance and rraining Project the Mission has assisted in the establishment of a critically needed regional resource early grant objectives of institutional development were transformed over the last few years to partnership wit1 -his PAIdO collaborating center

CGARECs role inthe rlion will continue to be monitored by the Mission Moreover it is expected tiat the productive relationship started under the project will continue into the future insuch areas as AIDS prevention and control for example

V Lessons Leirnel

[he Missions associtiori wito the Caribbean Epidemiology Centre has over the yeArs provideJ the grist for many lessons about development programming in general and specifically ii this geographic region

1 rhe period itforIei tie Centre to successfully grow into a confident regional instiL tiL stiests tiat )rganiational itevelopment goals reluire time to be ichievel

2 ro minimi tio p)ssibilitv )f instittixjlal [mdence however A strategy should be enploe] to broidea tne expertis of the Drganizition one step it i time -s tisks ire ccolnplisied and )nfience is gained the organiAtion should he expectedJ to assume responsibility for its new expertise and further grint support shoulJ be tirgeted to financing start-up of new critical ircs

1]1 AUis rowtn and eoxpansion over the I st years shoulJ he shylesson to othr development )rqganiitions of tne importance of proviJinng tiwely relevant service to ones constituents ta earn their respect trust anJ support

4 rhe organiational structure ind management formula of this institution should be studied to see whether they can serve as useful models for regional cooperation inother development areis

r ~t~ ~ ~ A ~APPENJDIX 1

COMMODI TIES

~1 ~~~~o -- --D u- shy

deg t ] E --oE -

pound -

T

A

r

0

I

-

shy

S

r -pound shyr -shy

~~~ -shy

r

-

t

0

-

APPENDIX 2 SUMMARY TO THE 1986 DIRECTORS REPORT

10 BIUNAIT

The programme of work for CARIC in 1966 is set out indetail in the respective sections

It has been as in 1965 a difficult year for the membercountries vith economicsevere Constraints becoming the normThe effect of rapidly failing oil prices through the inabilityof OPEC to atabilise the price has been especially detrimentalto the economy of Trinidad and Tobago There has been the finanshycial collapse of both large and emall private sector enterpriseswith resultant unemployment and general uncertainties in the workforce Productivity and job security replaced increased salnrydemands in the dialogue bulltween maragement and workers CAREChas not escaped these economic difficulties

The previously reported trend of andlate incompletequota payments has been experienced again but worse in 1986 thanin 1984 nd 1985 On November 7 when this report is beingdrafted only of7 the 19 member countries had completely paidthe 1986 quota In addition the United Kingdom has provided afull contribution It it indicative of continuing sunport that16 out of the 19 countries have made contributions in 1986 sothat 9 contributed in respect of previous yearaSuch a situation resulted in a severe cash flow problem offsetby PAHOs banking role in making up deficits in operating exshypenses throughout the year

The Director and staff have continued with effortsreduce operating tocosts yet maintain a dynamic quality operationto satisfy the cbanging needs of the member countries In orderto further enhance the value of the quota contributions ashytrabudgetary funds have been sought for both service and research activities

The United States Agency for International Development(USAID) hs continued to support service and training activitiesin hospital infection prevention and control and traffic injuryprevention and control throughout 1986 In addition extraworkshopscourses were supported through agreement to utiliseproject savings Indeed by mostthe efficient use of the USAIDproject fuds since 1979 it was possible both to deliver on tineall scheduled activities and have savigas of U58145000 USAIDagreed to the utilisation of thee savings for the aboveshymentioned extra workshopscourses and for a mew occupationalhealth project at a cost of US$122605 The USAID funding willcomplement the seconduent by the US National Institute of Occuoashytional Safety ard Health (NIOIN) of a medical epidemiologisttwo year assignment on a

at the Centre from November 1966

I

The Centre hassearch made an applicatiun togreant (US$70000) BOSTID forMoctesuma as amp to evaluate the use a reshy

biological of Tozobagent bites(predator larvae)Asoe eeamplpt-i mosquito in Union Islad 3t andVincent the

In co-operation with Professorthefrom University of Courtenay Bartboloethe Westsuccssful Indiesbid to CARIC submitted athe Naticnal Cancer Institute for a 3 year conshytract worth US$7640 toLeukassiaLymphoma 3 5 study the Epidemiology ofVirus Human T-Cellregion in Trinidad and Tobago and the CaribbeanWork on the project beganwith previous in Octoberresearch 1986 but is linkedwork by Professor Bartholomew and histeam

PAHO has submitted a regionaltional project to the USInstitute of Allergy and Infectious Diseases for Human Inshy(HIV) Researchmunodeficiency Virus

Na-

PAHO resource Centre CAREC was proposedfor the as theCaribbeanIn the interim to executeCAREC secured the projectUS$10000 intramural fundings forHIV studies among migrant workers

An applicationDevelopment is being madeard Research Centre to the Internetional(IDRC) forPrgramme for St a Hepatitis B vaccineChristopherfunded followingby USAZD which revealed a 1985 CAREC surveyprevalencemarkers in meubers of of 612 H3V sarologicrandomly selected households aged 6 monthsto 44 years

In SeptemberUniversity Professorof Malawi

1986 J Kaminjolocompleted of theattachment his one yearHis expertise in sabbatical leaveanimalMinistries virology was utilised byof Aariculture theHealthCAREC staff and Environmentto strergthen their and also bythe occurrence own capacityof enteric He investigatedbacteriain Chalmydiathe urban pigeon population and Cryptosporidiawork of Porton rotavirus of Spainsalmonella and initiatedanJ Cryptosporidia in calvesdiarrhoea with

His wife Althea a trainedus with HIV nurseresearch among migrant vorkers was able to oasistVincent end intoe Grenadines

many Saint Lucia God itTheirspoke highly now friendso their contribution at CARIC

oour Just prior at a party give is theirto their departure

We welcome Drepidemiologist Richard Keenlysidewho Joins us In NZOIN a sabbatical November 1916 Althoughleave his presence met efacility cautiouesof experts being theassigned at most welcomeby the Centers for Disease so direct costControl to CARsCis being ordered for both

As the year close equipmetassessment industriaeeavirommsetIt is anticipated that

sad medicalthrough computer link-up the

2

well as addi-Centre vii have access to the NIOSH data base of

the arises The prograisetional cesultant services as need

- GrenadaEastern Caribbean countrieswill be direated to four

but trainingSaint Lucia Dominica and St ChristopherNevis

least four more countrieswill be offered to at

Acquired Immune Deficiency Syndrome he continued to be

PANOVEO hap provided guidelines a major public health problem had been introduced from the

and standardised reporting systems a five-day workshopThe first three days of

3rd quarter of 1986 the Centre from January 27

for national epidesiologists held at review the Caribbean31 were used to thoroughlyto January the Centre from Sepshyat a workshop held at

situation Similarly was a review of screening techshy

tember 8 to September 12 there so well as an update

niques for blood donors and high risk groups

on CARI confirmatory resources

MIV researchersCAREC provided laboratory support for

ofend and undertook studies migrant farm in Trinidad Tobago

Vincent and Saint Laciamp who work for periods upworkers from St to six months annually in Florida At the request of the

screened migrant workers in Dominica andalsoGovernments CAREC

of blood donors from Grenada Saint Lucia and St a sampie

for antibodiesconfirmatory testing HIV Vincent By offering

support to clinampcians CAREC continues to provide vital and

researchers

Conference of Ministers Pesponsible for HealthAt the

1986 the Director provided an upshy(CHMC) held in Guyana in June wasdisplay Raphasis

date on AIDS complemented by a poster

given to the impotance of surveillance counselling and the need

educationfor frank effective public

its many ramifications continue to be Although AIDS end media the continuing threat of

the dominant health item in the was perceived by national

dengue and its complications and PAHO personnel as quantitatively more potenshy

epidemiologists of the new vector Andes

tially serious The introduction capacityUnited States with itsSouth Westalbopictus into the

causein both urban and rural environments was for

to flourish further concern

at the CMHC in June The Director presented a report

This Report had been prepared by the vector1986 on this new

PAO Vector Control Adviser Dr I Knudsen and the Director

dengue surveillanceprovided additional information on

voctor was recog-National capacity to identify this

nised as a priority and through a combination of funding provided

and regional funding it was posshyby PANOWHO representativces

26 - 30 fcr 20at CAREC Octobera 3-day workshopsible to hold vector control inits Included in

participants from national

3

this group were participants from the non-member countriesAruba Curacao Martinique and Venexuela and shyfrom Puerto Rico resourceand Haiti personnelthereby enhancingchange of information and early warning systems

Caribbean inter-

AsesFalbo ictustyres from thAe rEast was imported intoported tyres There is a Caribbean trade the USA in usedinand health authorities will need

used imshyother pertinent Government to establish withmonitoring agenciesmeasures adequatiHovever control source tyres aLdand surveillance are not theshould only potentiiljbe intensified control other to identify andsources

Although in the Caribbeanbeen reported from Puerto Rico (types 1 2 and 4)

limited dengue activitySuriname Trinidad has (type 2) French Guianato therespond to epidemicpandemicCentre has maintained capacity

spite of This has been achieved infinancial constraints through the creation ofversatile work force of laboratory a flezibleimmediately and personnelSuch effectively reassigned capablea cadre has been of beingcreated to areas oftraining at greatest needthrough a combinntion ofthe in-serviceCARbullC Council

Centra and short intensiveagreed that in courses overseas Thefrom 1986 US$30000the Government couldcontributions be utiliseddetailed in forthe appropriate staff trairing

bers sections of Asreceived overseas the reporttraining 7 saff memshytraining In additiona comprehensive to the on-the-benchtraining programmenicians was for junior techshyoffered starting vith parasitology

conducted A by

four day management vorkshopMr Sam Aymer for 15 supervisorsstimulating experience PWR Bahamas yaaThis proved to be afor allmanagement training programme is

participants and a follow upproposed for 1987

propriate All training activities vereaccess restructuredfor CAREC staff to ensuretional personnel to programmes organised ap-

There is for nashycontributed both to no doubt that such opportunities havethe maintenance ofstaff morale given the economic

a quality operation and tothe Staff uncertaintiesAssociation (CASA) of 1906 Indeedhas organisd additionaltional and self-help activities outside of work hours educa-

As in the recentcalled pastto assist the Centrein staffthe havehas been given in the crisis type epidemics though

not been investigatio assistanceDominic Hepatitis of a Rubella

flaccid A and Gastroenterit outbreak inParalysis in Montserratand Typhoid Acutefavor outbreaks in Jamaica AcuteViral illness in Grenada and Neonatal Sepsis in Trinidad The rangenot and number ofdiminished telephone- eg consultationsfrom the merits haveof HIV blood screening tothallium Poisoning

4

Although in a state ofhurricane season requirig the

(June to Novereadiness specially during thefervice ) no nationaoccurred disaterofO PAHObullDisaiterCARIc provide Preparednessan epidemiologis Team

leader for the t and a substituteteam

In Augustprovide BWIA kindlyMiami

a courtesy transport agreed to CARECKingston and Tobago - system for laboratory request toThi specimensprovided by LIAT and Guyana Airway

Complement fromexiatingOn national servicesItairlines such O

as BAhaauair ptimum utility dependCayman Airways providshying feeler servicies

The seniorfered epidemiologistto the the DrFebruary PAHO programm Mirta use1986 and by e in the was trans-Dominicanreason of Republicfinancial constraints in became part of

CAREC has been frozen through 1987 her post atAlmost Trend PAHO beadquarttre hieultaneOuelyAssessment new urit CAREC

(HST) which of Health Situation andquarte r Epidemiology had absorbed staffunit frombeen (formally the headshypreViouly linked) HCE with whichPAHO This CARECorientation broader hasrole isQuadrennium 1987 and Programme Prioriti a key elmaent in- 1990 for PAHOAmerican which duringwasSanitary recently approved theConferencemedical atepidemiologist CAREC with the Pannlyleave and and depampndent one fulloverseas absences of

on the Director time to fully contribute that individual to cover the

tothese constraints these new development is in no poAition

September 4 to it was agreed Notwithstandingat a meeting held5 withto the at the CentraCaribbean HST staff and PAHO Statisticiansfunding that CAREC could assignedinto bea resource developedfor withdata extraprocessing analysisurewrse andrs support for both national and PAHO microcomshy

tal The Centie continuedInfection and Traffic to execute the projects for Hospi-USAD In Injury Prevention andthe Traffic Controlwere held in Injury project funded by-ulti-ectoralGuyana DominicaBahama Trinidad workshopsEPidMiOlogical and TobagoLucia studies andand technical have the

undertakenTrinidad support provided been

in Saint for

and Tobago for studies the Draft have in Suriname andmedical beenassessment prepared

new vehicles of drivers and for guidelines

A print for theestabliahed and licensingaudio ofvisualOn November librarytrauma 24 hasworkshop for - 25 the beenfirstsultant accident staff of a risefrom John in conjunction ofHopkinsPrincess University with a con-Margaret willHospitalBahamas be boldNassauBreath at theanalyfer New Providenceequipment Islandavailable for loan has been obtainedto national and idresearchers

5

l

EzcellenttiOn Of progressthe hashospitaland infection been made withcost studie the implintwere completed tHelh andHeat w progent he plenceTwo basic con--lidtr prenm to Mitraining tnCdt to ofTjbewv~t~tnS8Q~courseg twere hold in April In Surveillance and Controlfor Infection Control Nurses and Physician

ZQ-countryin follow up vifite have been made

tals eleven countrieshas been drafted The Hospital to 15Senior Infection Contra hospishytending laboratorya CAREC workshop staff manu from September

of the Caribbeanatshythse days discussing to f t

a to 12 spent twoe i b rato Ofin h ositainfection control thofe olheei lab rat rieAlthough in hospitalcompleted the USAIDin fundedJune 1985 projecttraining CARIC on Foodcontinue Safetyof the trade andlaboratory capacity inopectorate to be a resource was forfor Thereutilised research in rsoin a school 0 campylobacter limited

feedingtion with Mr service in chickensT Kirby The Directora sanitarian in conjuvcwriting from Project Hopis a Food Inspectors Manual GWenada

for the CaribbeanThe Centrethe continuessub-resional to benefitadviser from thedent Control in EPI and assignmen

Good progreas the regional t ofvaccination advisercontinues in Roshycoverage with to be madein Belixe and innovative in improvingoperational mass vaccinationdetermine research programmecoverage and in on Guyanarefrigeration improve progranm and Jamaicamaintenance management to

nicians and was A workshopone held in PuertotunitY otcAREC maintenance Rico forto participato tecbniciano techshyassist with the

The Rodent Control had the oppor-Adviser continuesfood Safety progrem toforts for and strengthen national fshypast control progress

In FebruaryAve Cmejo-MaYnard 1986 a new Administrativeappointedwithout wa Officera fulltine thus ending MrAdministrator a tensettled monthin periodher neW assignment gave M90 CJOMaYnardputerisation

of special oncethe Centre attentionA proposal to the coo_wasfacilitie prepared for computerPayroll fot datainventory processingwith and laboratoryword processingFA-O headquarers record accountingsoftware inearly August Thi was reviewedio being received in The hardwareNovember now be andoffered In-serviceto staff from all training willPertinent units

The Senior Maintenance TechnicanWorkman Mrretired Randolphin AuJguetretirement 1 We wish him a long

In and happySeptemberOswald Ftveck we welcomedwho has had N Workeasprevious eperiesce laboratory

general building maintenance In c The opportunity has

and been taken in

6

the linlt of changin needs to review the total Maintenance Proax to te ampinlon8aintenane PersoannItheT facilitie and training-te needThe Team plant for theto the T I nowcae fullylaboratory Th_Pu-l oerational

1 th T ri d rewiring supplying1 9 8 5 tob9g5 ha-- P r o v e t u A copy and linkagein troedto Healha l t haoratoL _ba n d l i n k a t o - $Ome rhe sInvaluable hihobe wag ont - -Cmpleedlabo in 1966 Ina iolPletedato y ad training functions from nati cn l Po erThe deterioratindton odliein diitration oft atinegw re teand Surveill

digital diall nul 0 directctoY tmyOf k sy rstn evtlik d i~ in t eexternal hang Phonn Into considerationhe i

e e h n Company wereh en i oTel o pa y w rprovi th e 2 key lin e a t rto aofre xtr naL abo ra t r cac_ be tw er egs a lll s these 2 keo lddietainDirtoriendnd Surveilbet-enn- direc tthe v z e Ad lrentks tSurveillanc Director Administrator- 1-d-i eswitchingOnei r t o c important benefit ia

H d oei demiologist h e Surveillidaut te n l h c tht thTa alligtht tg ainThe e calls in the absence oflifl i n system to thatP the theave 1 -_ CpnY representative oneto be i i -loat cbh is suggetc onstrints end

and of itg usefultradeitwilhaeb ac value it u Until breakdownfeaCooai repairoIn all isCOer these no lOeo oS endeavours r

m thereCoo hasCAR~c ert iofof been themembers fullOf Participatedta f fullStaff Associationd specialwho meinuardingwhilt t oshuldshd ldn bb ma e ofe~ themadethe e f thOffered interest ofconstructiveCentre aUlgestion 8 fo1pirds o fori Staff Rules andmr onovdOperations On off the

cereaony 5thfor September3 PAHOtaff and elevenreceived CAJtC2010 locallyarYer had r Lon Service

PAHOo E 6taaf Dr lBrb r a l ( acruted staOne Award Hul sw ofh1 publ cReprice toofheTrinidadGold _M dalsa O f Me

V r

i it

rol ogist dward s one of thbeforeBraaml e rvi and of M r 0Yat fr-f om 2 as r c ived Loc al Tobago h ed ra e i tO _nw esa t f for d-tn of th~ ~~ ~l

l fw o d h e sidenb~ of-vrsLsoewhoa wi rstked for -ealthto twenty Years the1egional Aubd Peubli th ec Health-Virus Laboratory7 n nha aS r i e r - r -to twervcm ba wok r t eranging d f r t e T i shyfrom T i d dthirty-threeOlg national Counterparts

and pcllythat laboratory thentcouraa- nationaldortitedstodemand forlantce s ainformation ad rovidwhich of prveasdegrlanlation is the liboo suchoan soriauat suchilI wouldteniuport like to expressdeor te myOfficer i personal

who Responsbledo-red at the Guyana Cofere forthe work ealtht o u ministers at

Plan mnd budget through

e th elr n SUe mbe n-shy

the Pan American Sanitary Comfereuce a-tg1eboo the tamed the

Multilateral Agreement extension for PAHOe managemenCentre through 1988-90 of the

play a major role in facilicatingcluding

The host country Trinidad and Tobago has continuedthe continued the operation of to upgradini the Centreof inshythe buildingtoilets e n

TechnicalLaboratory links withhave thebeen strengthened Trinidad Publicthrough HealthDirector Dr B Watoon in March the appointment of a1986

CAREC hasGovernmefundd provided administrative to en St Joes Cardiovascular aupportth ton year project to the 1986 prospectie- whichNeOXtiations cohort ii due are studyIn progress to

on Decembercure funding 31

this work to conTinue

Scientific 10 MarchAdvisorythere wereCommitteeoverlaps the annualAt (SAC) and Meetings ofCouncil withthe CARICbeen moat planned

the meetings and throughout the year mneber have supportive SPeviafrom its inception ampention is made ofJune of Dr Phil the roleDr Brachman who served

Beachan who in SACretired from CDCmAn of SAC was an both inthe uidiviaual a member andlent links with CDC and the

mainly responsible past Chairshynel invaluabl forto the Surveillance e assignment the excelshytive and and Training of CDC personshyhappy retirement which

Units We wish his anhas begun acshysent at with a faculty designEmory University -

All CARECdeath rtaffin June were maddened byof Dr o the newsUniversity 1966 AZ rds ton of the suddenof Vice Chancellorthe CARIC

the West ladies ofDr theCouncil Prestonsinceis link it irception hadbeen Chairman ofwith UW at the thus providingunique highet love a contiueoanner of conducting the Councile Dr Preatoin financial withmatters and wise busine his

counsel will be bi expertie

i sdbe Futu er - by us allIt s e ~ n y us a 1

Prolgreae PANO to re-orientinPriorities 8 its servicesprepared for the Quadremnium to implement

pr vestio its n endSamuel 19g7-19pt oprogramme CARICeevemtggo i m cot_ rol focussinge n has

ut communicable onn 2 0 keyl eouemen t c b0a0e0 nd 0Cseumicablesacialis vulnerableQe8pai groupo 1

disshyfor CARIC (2) gsnogemeaton epidemLol Of haoviedgeutilisotiom for csI aSmaysi withhealth ampadil s i 6 p r iub aand local levels 7 hPlanin Particularly i t r ditst e esd it tn communicabletecbaical disease CAIIC willcapacity to ealmntsiPoliomyelitis diagnoee Nry up t o-dateLtectioIt to anticipated

that deniue ed

ao part of the FANO

I

Regional programme to eradicate poliomyelitis additional fundingwill be provided so that the Centre canintroduce sev also service Haiti andtechniques e oltgo suclootide mapping Im coordination with PANO vector control consultantsCAREC will maintain surveillance for densue and the early detecshytion of Aedes alk2oictus importation

funded by lostid The research programmeto field test the effectivenechites moctenuma against of Tozorhyn-Andes Ae ti will bein Union abd St fully operationalVincent and Grenadines

CARIC will be responsible for AIDS surveillance iuInglieb speaking Caribbean and theSurinameresearch will be in It is anticipatedprogress at that Lucia St and

least in Bahamas Barbados SaintVincent ths Grenadines Suriname andTobago Epidemiological Trinidad andstudiesLeukemiaLyaphona of Human TCellvirus viii be in progress in Trinidad andTobago Grenada end Barbados Multieectoral workshops totraffic injury prevention and control will be held in discuss

and special workshops 7 countriesfor Accidentcountries DepartmentSupport staf1 in whose

will be given for epidemiological 4 is determined studiesneed

by these workshopsthat studies of alcobol It in anticipatedblood levelundertaken in in traffic injuries will bethe main Accident Department of 2 countries

In Hospital Infection Prevention and Controladvanced workshop will a two daybe held at the Centretion control nurses in April for infecshyFollow-up visitsprogrammes will to reviewbe nationalundertaken in 8 cointriestrol manual will be An Infection Conshycompleted and distributed

Activities of the Occupationalclude risk asesmeent including Health project will inshyindustrialcal environmentstatus of workers in and medt-Grenada SaintCbristopberNevis Lucia Dcminica and StA ten day training course willJune for 8 Eastern be planned forCaribbean countries There willbuild up of be aprint and audio-visual rapid resources

Although final arrangements arehoped yet to madethat funding bewill be obtained by it is Government to the Trinidad andcontinue the Tobagoresearch work into chronic liseasesthe St inJames Study cohort

It is anticipated that bycomputer systems will in the end of the firstbe quarter

administration place end staff treand for financialstores and laboratory records

Althougb there areveillance sons trained personnelUnit CARECe role as in the Surshya resourceeenlyse for on epidemiolosicaehealth Planning will remain limitedtional human resources unless addishyC-e-b-n-d-active in the improvement CAIC wil- however beof the quality of mlaoreatjon includiag

9

daenta doeath8606rld the devlfopmcat10rt f c ioof and injurya traffic injurymorbidity

databaseand mortalityat CARIC

ReferralbacterioldegJobace laboratoryi th~ PPsaeitologto-- servicescordance with forand entomology will be provided in vithe agreed fo vrloytesting proga servicer e prioritie acshy

on for bacteriology The proficie nca voluntary participation and parasitologyin microbiology basis will continCARIC will provide(LlWx)

for medical students in traiuinand Surina BarbadosOn-the-beach (University Of (UMX) TrinidadSuriname)training for national CARIC willtinue the provideCertificete laboratoryCAREC junior level personnel

technicians in-house More snioo atni conrefresher staffOverseascourse and will be exposedappropriate to

including opportunitiescourse at at two ortinitgeincot

Oligonucleotide to the Tropical technicians for a CDC course on Institute in Amsterdam and

the serology one participantmapping of polio virus

National The SurveillanceSurveillance Unitinservirce - will continueystem n t ri l theiyeve in 19 o t n e th reviewcountries r - of the Guyana

training programs as and participatewill requested inbe provided Thewith Universitytechnical oTits medical and materialstuden supporttraining progress for

CARECprogramms will continue

tbrough to supportthe nationalprint materials loan of visual ad food satyThe andFood Inesctorse the provisionlield tested Manual oftand willthe final be completedveiion printed and distributed monitor

a all thb endeavourcesta mnagemetand make willof a quality operation internal adjustments Continue totheThe codputerngati for maintenancemanagerial activities should further of te nteuemaia e t pCntrols mainfurhe hnc -thisThe processinvestmentwhee byfeoniblo by the member countries will be enhanced

9trabudgetary1915 Report financingdonor want Amembe tis nheeco clear evidence ofThe ntionedinescapable trend to fAna

othbconhequences pay quotea laterof serious and latercash haflow problems icret difficulty AttampCt1a edtrabudin$ taf feaiae tn mitiYfnig n anan

-2shy

laboratory equipment and supplies for CAREC and the CNICs and (4)expanding and diversifying the production and dissemination of educational materials and (5)establishing a data processing center at CAREC In addition to these broad directives the grant identified two programmatic areas to receive attention improving the cold chain distribution of immunizations to CMCs and undertaking a zoonoses surveillance study

A mid-term evaluation of the project completed in early 1981 indicated that CAREC was on schedule in providing training to health personnel and in building up its core capabilities to produce technical materials for health training in the region Major recommendations for CAREC by the evaluation team included intensifying surveillance and EPI activities improving evaluation procedures of training programs attemptiklg to tailor training more to specific country needs and including nurses in surveillance training Recognizing that the improved national epidemiology programs were in many cases still ependent on one individual at the country-level the position of deputy epidemiologist was introduced to the region The evaluation team applauded this effort but noted the need to provide 3 supportive career structure for such individuals

In 1983 the implementation plan of the project was expanded to provide support for the introduction of basic epidemiological components into tOe regions nursing curricula and the design and introduction of a program on sexually-transmitted disease This amendment also reflected discussions between CAREC and USAID to begin to wean the Centre off IJSAID support by including covenants which sought to transfer funding for key CAREC positions from the grant o CARECs core budget Training and siu eillance programs for improving the haniling storage arid transportation of f )d were introduced to the project scope of 4ork in 1)81

A final evaluation of the project was conducted in February 198S rhe evaluation team reported that training had been provided to over 3400 course participants (representing some repeated attendance) including national epidemiologists laboratory directors statisticians public health nurses public health inspectors laboratory technicians medical students hoteliers food industry personnel and others It noted that CARECs capacity to produce appropriate training materials had greatly increased during the project and that a significant improvement to both the surveillance and laboratory capabilities in the CMCs had been achieved The addition of new staff and the replacement of expatriate staff by qualified West Indians was also reported

Khile the evaluators noted that CAREC had completed nearly all of the tasks outlined in its scope of work it further cautioned that the constant threat of diseases such as dengue malaria polio and gastroenteritis and the emergency health problems of motor vehicle injuries chronic disease and occupationalenvironmental hazards nean that there will he a continued need for a regional epidemiological institution and one that is capable of a4justing to new needs while continuing to support existing control and prevention efforts Based on the recommendations of this evaluation team the project was extended to June 30 1987 and funding was provided for two new programmatic areas (nosocomial infection and traffic epidemiology) As this work progressed in August 1986 RObC agreed to collaborate with the National Institute of Occwpational Safety and Health by financing the start-up costs for a CAREC occupational safety and health program rhus during the last two years of project funJing while CAREC improved on the skills

-3shy







-4-












-6-







-7-










-8-


2 Food Safety


3 Staffing








-9-





V Lessons Leirnel







COMMODI TIES

~1 ~~~~o -- --D u- shy

deg t ] E --oE -

pound -

T

A

r

0

I

-

shy

S

r -pound shyr -shy

~~~ -shy

r

-

t

0

-


10 BIUNAIT







I





Na-











2






















researchers






















3


Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9

















-3shy







-4-












-6-







-7-










-8-


2 Food Safety


3 Staffing








-9-





V Lessons Leirnel







COMMODI TIES

~1 ~~~~o -- --D u- shy

deg t ] E --oE -

pound -

T

A

r

0

I

-

shy

S

r -pound shyr -shy

~~~ -shy

r

-

t

0

-


10 BIUNAIT







I





Na-











2






















researchers






















3


Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9

















-4-












-6-







-7-










-8-


2 Food Safety


3 Staffing








-9-





V Lessons Leirnel







COMMODI TIES

~1 ~~~~o -- --D u- shy

deg t ] E --oE -

pound -

T

A

r

0

I

-

shy

S

r -pound shyr -shy

~~~ -shy

r

-

t

0

-


10 BIUNAIT







I





Na-











2






















researchers






















3


Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9






















-6-







-7-










-8-


2 Food Safety


3 Staffing








-9-





V Lessons Leirnel







COMMODI TIES

~1 ~~~~o -- --D u- shy

deg t ] E --oE -

pound -

T

A

r

0

I

-

shy

S

r -pound shyr -shy

~~~ -shy

r

-

t

0

-


10 BIUNAIT







I





Na-











2






















researchers






















3


Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9

















-6-







-7-










-8-


2 Food Safety


3 Staffing








-9-





V Lessons Leirnel







COMMODI TIES

~1 ~~~~o -- --D u- shy

deg t ] E --oE -

pound -

T

A

r

0

I

-

shy

S

r -pound shyr -shy

~~~ -shy

r

-

t

0

-


10 BIUNAIT







I





Na-











2






















researchers






















3


Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9

















-7-










-8-


2 Food Safety


3 Staffing








-9-





V Lessons Leirnel







COMMODI TIES

~1 ~~~~o -- --D u- shy

deg t ] E --oE -

pound -

T

A

r

0

I

-

shy

S

r -pound shyr -shy

~~~ -shy

r

-

t

0

-


10 BIUNAIT







I





Na-











2






















researchers






















3


Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9

















-8-


2 Food Safety


3 Staffing








-9-





V Lessons Leirnel







COMMODI TIES

~1 ~~~~o -- --D u- shy

deg t ] E --oE -

pound -

T

A

r

0

I

-

shy

S

r -pound shyr -shy

~~~ -shy

r

-

t

0

-


10 BIUNAIT







I





Na-











2






















researchers






















3


Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9

















-9-





V Lessons Leirnel







COMMODI TIES

~1 ~~~~o -- --D u- shy

deg t ] E --oE -

pound -

T

A

r

0

I

-

shy

S

r -pound shyr -shy

~~~ -shy

r

-

t

0

-


10 BIUNAIT







I





Na-











2






















researchers






















3


Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9


















COMMODI TIES

~1 ~~~~o -- --D u- shy

deg t ] E --oE -

pound -

T

A

r

0

I

-

shy

S

r -pound shyr -shy

~~~ -shy

r

-

t

0

-


10 BIUNAIT







I





Na-











2






















researchers






















3


Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9

















deg t ] E --oE -

pound -

T

A

r

0

I

-

shy

S

r -pound shyr -shy

~~~ -shy

r

-

t

0

-


10 BIUNAIT







I





Na-











2






















researchers






















3


Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9


















10 BIUNAIT







I





Na-











2






















researchers






















3


Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9





















Na-











2






















researchers






















3


Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9






































researchers






















3


Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9


















Caribbean inter-








conducted A by









4
















in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9
































in Saint for




5

l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9

















l
















and been taken in

6










V r

i it




























that deniue ed

ao part of the FANO

I














9


























V r

i it




























that deniue ed

ao part of the FANO

I














9





































that deniue ed

ao part of the FANO

I














9






























9

































Documents

EPIDEMIOLOGICAL SURVEILLANCE AND 538-0027pdf.usaid.gov/pdf_docs/PDAAX719.pdf · The Epidemiological Surveillance and Training Project Agreement ... strategy of improving the cost