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Mr. Speaker,
Honorable Members of the House of
Assembly,
I thank you for the opportunity to
address you on the recent cluster of cases of Malaria, which occurred in
Exuma and inform you of the progress to date.
There has been considerable concern
throughout the Bahamas regarding reports of Malaria on the island of
Exuma.
These reports have also been circulating internationally causing fear,
among Bahamians generally and Exumians in particular, as to the risks to
their health and the consequences for the local economy.
I am happy, therefore, to confirm that
local transmission of Malaria on the island of Exuma has been
successfully interrupted. We have found no new cases for the last eight
days and we are optimistic that we now have the matter under control.
This possibility of Malaria first came
to our attention on Saturday May 27th with a report that a person who
had been in Exuma from May 4th to 7th had
consulted a physician in the United States around May 24th,
with persistent symptoms, which had started while he was on the island.
He was diagnosed as having Malaria as well as another infectious
condition.
On Sunday May 28th, I met with the
staff of the Department of Public Health, of my Ministry, to devise a
strategy to investigate the initial report. As a result, two teams were
sent to the island on Monday May 29th to carry out the
investigation. One team consisted of members of the Surveillance Unit of
the Department and the other was from the Department of Environmental
Health Services of the Ministry of Energy and the Environment.
The Surveillance team, then led by Dr.
Mohammed Imana, the Department’s epidemiologist, met with members of the
local health teams and reviewed the log books of the clinics for the
previous month to determine whether any patients had presented with
symptoms of Malaria. This is called ‘Case Finding’. Additionally they
took blood samples from vulnerable persons to test for evidence of the
parasite. All tests were negative. This completed, they began active
‘Fever Surveillance’
The team from Environmental Health led
by the Assistant Director Mr. Andrew Thompson, set mosquito traps to
look for evidence of the Anopheles mosquito, the only vector which can
transmit the malarial parasite. They began the preventative measures
necessary to eliminate or at least minimize the mosquito population in
Exuma. They then began ‘Geographical Surveillance’ throughout the
island.
No cases of Malaria were discovered at
that time. On Monday June 5th, a Bahamian presented to the
clinic in Exuma with symptoms suggestive of Malaria. Through the
alertness of the surveillance and public health teams in Exuma, this
case was detected, provisionally diagnosed and referred to New
Providence for testing and conclusive diagnosis. That patient’s test was
positive and he was the first to be admitted to hospital and started on
treatment.
What is Malaria?
We have already indicated that Malaria
is not endemic in The Bahamas but sporadic cases are encountered from
time to time. Such cases are imported into The Bahamas by foreign
persons who come here from areas where the disease is endemic or
occasionally by Bahamians who have traveled to such countries. In 2005
only one case of imported malaria was reported.
Malaria is a parasitic disease caused
by the plasmodium species and is transmitted by the bite of the female
Anopheles mosquito, which feeds from dusk to dawn but is not prevalent
in The Bahamas. The mosquito becomes infected when she bites an infected
person. The incubation period is between 7-14 days after a visit to a
country in which Malaria is endemic. Mosquitoes, which are commonly
found in The Bahamas, are the Culex and Aedes species. They do not
transmit Malaria.
It is in the rainy season when
mosquitoes tend to proliferate. They tend to do so in still water
collections. Indeed mosquitoes can breed in collections of water as
small as that which can be held in a soda cap.
The common symptoms of Malaria include
recurrent bouts of fever, chills, body aches, pains and headaches, and
in some cases, nausea and vomiting. These symptoms, individually, are
present in many other diseases and are not diagnostic of Malaria.
Diagnosis is most commonly made by a microbiologist who examines blood
smears but there are other tests available.
The Investigation
Once the first case came forward, a
three phase process was initiated. In Phase One, emphasis was placed on
identifying any persons in Exuma who had symptoms consistent with
Malaria, taking blood samples for evaluation and treating them where
positive smears were found. The examination of the slides was done by
the staff of the Princess
Margaret Hospital laboratory.
This work was later greatly enhanced by
the arrival of two microbiologists, one of whom, Mr. Krishnalal, is from
Guyana and is responsible for their Malaria programme. The other, Ms.
Shree Baboolal, is from the Caribbean Epidemiology Centre in Trinidad.
They all worked tirelessly in the identification of all positive cases.
Over 600 specimens were taken for
testing. They found evidence of both recent infections and old
infections in sixteen cases. A total of twelve cases had recent
infections and four had old infections.
Of the twelve cases with recent
infections, nine were Bahamians all of whom live in Exuma or visited
Exuma within the past month; two were Uruguayans, who work in Exuma and
one, a Haitian national, was also employed there. Subsequently one
additional Bahamian was diagnosed in Canada.
All of patients were treated with
Chloroquine and all responded well to their treatment without either
severe illness or deaths. They will be closely followed over the next
several weeks and may receive supplementary treatment if it is
required.
In Phase Two, the surveillance team
carried out contact tracing by seeking out anyone who may have had
contact with infected persons. This was done by going house to house,
within a mile radius of where the infected persons live, to look for
anyone who had symptoms. Blood specimens were taken from contact persons
for testing. This Phase is now complete and I am happy to report that
all of those tests were negative.
We are now about to begin Phase Three,
which is to carry out a sero-prevalence study, in order to establish to
some degree of certainty, the likely source of the infection.
Vector Control Activities
In a parallel move, entomological
surveillance and vector control activities on the Island of Exuma were
intensified. These included light trap and human bait collections in
numerous locations which were identified as potential sources of
Anopheles mosquitoes, the only vector of malaria. The entomological
surveillance focused initially in areas where suspected malaria cases
reside and was subsequently expanded to other potential transmission
areas.
Results of these activities indicated
that the Anopheles population of Exuma is extremely low. Indeed in most
of the locations surveyed it is non-existent. These findings are
consistent with the increased vector control activities in the form of
adulticiding/fogging and larviciding which have been conducted by the
DEHS and suggest that no active malaria transmission could take place
since the initiation of interventions.
It should be remembered, however, that
there are other types of mosquitoes in Exuma which are regarded as
nuisance mosquitoes, but they are unable to transmit the malarial
parasite. PAHO recommends that the ongoing routine control activities of
these nuisance mosquitoes should continue. The Environmental Health
team is continuing the heightened mosquito control activities for as
long as is necessary.
Mr. Speaker,
Honorable Members,
From the beginning, my Ministry treated
this matter with the utmost urgency and sensitivity. We were aware,
firstly, of the potential danger to the public’s health and the need to
prevent any widespread dissemination of Malaria among the residents and
visitors of Exuma.
We were also aware of the potential
threat to the economy of Exuma, which is showing unprecedented growth
and vitality and the need to minimize any adverse effect thereto.
Moreover, having regard to the
importance of tourism, it was important that we get the matter under
control in the shortest possible time as any delay might affect not only
Exuma, but the entire Bahamas.
PAHO
From the outset therefore, we engaged
the assistance of the local representative of the Pan American Health
Organization, [PAHO], Mrs. Lynda Campbell who enabled us to secure the
services of the aforementioned microbiologists; an epidemiologist from
the local office, Dr. Yitades Gebre, who is also a Disease Prevention
and Control Officer and Dr. Christian Fredericsson, an entomologist, who
spent ten days in the field in Exuma advising and working along with
DEHS staff. On Saturday last, they were joined by Dr. Keith Carter who
is the PAHO Regional Advisor on malaria, who traveled to Exuma with us
to thoroughly evaluate the situation on the ground.
These advisors not only provided
valuable assistance to the local teams but were also able to
authenticate the validity of our work to the satisfaction of the
relevant international health agencies. Indeed, so satisfied were they
with the procedures which were in place that on June 19th,
PAHO issued a joint statement with the Ministry of Health confirming
that the transmission of malaria in Exuma has been interrupted.
Mr. Speaker,
Dealing with the international health
agencies has been very challenging. Once it became known that cases of
malaria had been discovered and were being treated we received enquiries
regarding the risk to visitors.
Centers for Disease Control [CDC]
We were contacted by the CDC, in Atlanta, Georgia, which was concerned
about any health risk to Americans who were traveling to the Bahamas.
After intense discussions, which included the intervention of PAHO, the
CDC confined their intervention to a temporary recommendation that
persons traveling to the island of Exuma should take the anti-malarial
Chloroquine.
Public Health Agency of Canada [PHAC]
The PHAC published a report that a ‘Canadian traveler’ had contracted
Malaria in the Bahamas. This was interpreted by some to mean a Canadian
tourist. We contacted the agency and discovered that this was not the
case. The person concerned is a Bahamian student who returned to Ottawa
after spending a period of time in Exuma, which corresponds with the
time of the local transmission. We spoke directly with his physician who
confirmed that he did have malaria and that he was not admitted to
hospital because his condition did not require it. He is being treated
and we were informed that he has responded well.
We are also happy to note that there
have been no cases of Malaria in Long Island or any other island. The
screening carried out at the detention centre was only done because
eight detainees who were confined there had been in Exuma during the
relevant period.
Impact of Malaria
Mr. Speaker,
Honorable Members,
Two million people die each year from
Malaria. There are three types. The one found here is the plasmodium
falciparum.
In the Caribbean, only the island of
Hispaniola has endemic Malaria but there are many countries in the world
where Malaria is circulating. In South and Central America, only
Uruguay and Chile do not have endemic Malaria. Many countries in Africa
are endemic and most deaths from Malaria occur on the African
continent.
While Malaria is not endemic in the
Bahamas, we do have persons who live and work amongst us who are
nationals of countries where it is. We also have persons who come here
from such countries or who have traveled through such countries and may
have been exposed to the parasite.
Many such persons may have had the
disease in the past and have recovered. However, there are also persons
who do not complete their treatment and others who use home remedies or
‘natural remedies’, which suppress the symptoms but do not eliminate the
parasite from their blood. Such persons, in whom the parasite may lie
dormant, are potential sources of infection, if they are bitten by the
female Anopheles mosquito.
We are certain that the parasite, which
caused this cluster of Malaria was imported …someone brought the
parasite to Exuma. The determination of the source will be the result of
our intense investigations, which are ongoing. We have already
identified several locations in Exuma where the few adult Anopheles
mosquito and its larvae have been found. We are monitoring the movement
of persons and conducting sero-prevalence surveys in those areas. This
will ultimately reveal the source.
Once the source is found, we will offer
treatment to any person who reside in or frequent such areas or who is
identified as a potential risk for the transmission of malaria.
Recommendations
Recommendations for further management of cases include the addition of
Primaquine to the treatment regimen, case follow up, active surveillance
of contacts, and immediate treatment of all potential carriers of the
parasite.
Based on the findings of the sero-prevalence
surveys and in consultation with our international partners, we will
formulate and introduce policies to minimize any recurrence of such an
event in the future. Such policies will not be limited to Exuma. It will
be necessary to introduce them throughout the entire Bahamas, having
regard to the growing economy of New Providence and the Family Islands
The public is nevertheless advised to
avoid mosquito bites by wearing long-sleeved clothing when out at night
and in the early mornings and to apply insect repellents to exposed
areas.
We recommended to all persons,
Bahamians and otherwise, who are traveling to countries in which Malaria
is endemic to seek medical advice on how to protect themselves.
The Ministry of Health is reviewing its
policies with respect to requirements of immigrants from Malaria endemic
areas. This is likely to include proof of Malaria status prior to
issuance of work permits, including treatment of potential carriers.
Conclusion
Bahamians are assured that they may
visit Exuma and enjoy its rich culture without fear or concern for their
health.
I wish to state emphatically and
unequivocally that it is not considered necessary for anyone who visits
Exuma to take anti-malarials.
We had only a cluster of cases.
The disease is not endemic here.
The local transmission has been
interrupted.
The vector management has been
successful.
And we are certain that we will find
the source.
I am also pleased to share with you an
email forwarded from the CDC yesterday. It reads in part as follows:
“Congratulations to the Ministry of
Health of The Bahamas and to PAHO for a textbook demonstration of
outbreak containment”
Thanks
Mr. Speaker,
Honorable Members,
This episode has been an enlightening
one for me. It has demonstrated the capacity of the professionals who
make up the staff of the Ministry of Health and National Insurance,
especially the Department of Public Health, and the Department of
Environmental Health Services.
These Bahamians went above and beyond
the call of duty. They gave sacrificial service, leaving their homes for
Exuma and remaining there for almost two weeks and more, in some cases,
until we were certain that the cluster had been contained. They put
themselves at the mercy of the elements and put their personal welfare
at risk to protect the well being of the people of Exuma and the entire
Bahamas and to preserve our economy.
We owe them all a debt of gratitude.
Mr. Speaker,
In dealing with this matter, we
received invaluable assistance from the Ministers and Ministries of
Energy and Environment, Tourism and Foreign Affairs. I acknowledge the
interventions of the Director of Tourism and the Ambassador to the
United States of America with gratitude. I also wish to thank Mrs.
Melonie McKenzie, Director of Environmental Health Services and her
Assistant Director, Mr. Andrew Thompson and their staff.
Thanks are also due to the team from
PAHO/WHO, for their invaluable assistance, which is ongoing.
The work of the health team was
awesome.
I want to thank Mrs. Elma Garraway, our
Permanent Secretary and her staff, the overall team leader, Dr.
Merceline Dahl-Regis, Chief Medical Officer, Dr. Baldwin Carey, Director
of Public Health, Dr. Perry Gomez, Director of Infectious Diseases, Mrs.
Bernadette Godet, the Acting Administrator and Mrs. Gloria Gardiner,
Principal Nursing Officer, both of the Department of Public Health, Mrs.
Stephanie Dean, Surveillance Team Leader, Mrs. Vivian Lockhart, Manager
of the Bahamas National Drug Agency and Mrs. Cislyn Simmons, Supervisor
of the PMH laboratory and their respective staff.
Finally, I wish to thank the people of
Exuma, their leaders and the members of the business community for their
patience, cooperation and assistance.
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