The
Development Planning Unit
Government of the British Virgin Islands

NATIONAL INTEGRATED DEVELOPMENT STRATEGY

Health Sector
(continued)

CHAPTER 3
TRENDS IN THE HEALTH SITUATION

The health status in the BVI can be described as generally good. This can be demonstrated by some of the usual health indicators such as life expectancy, crude death rates, and infant mortality rates (IMR). Life expectancy rates have increased over the years, while crude death rates and IMRs have decreased.

The BVI enjoys good immunization coverage when compared to ten years ago. This, together with a reasonably good public health system and initiative, has ensured the drastic reduction of many critical health problems once experienced.

The prevailing social, demographic and economic conditions previously discussed, such as an aging population, and the influence of tourism have had implications for the health status and practices of the population, as well as responses and expectations.

Community health programmes continue to make progress in the promotion of health and longevity. Immunization for pre-school and school-leavers is actively pursued and much emphasis is being placed on school and domiciliary services. Mental Health, Dental Health Care, Family Life Education and Health Education have become integral units of the Community Health Services focusing largely on preventive and promotive health.

Nutritional status of the population is also considered good, in part due to the purchasing power of the population. Availability of specific food products may become a problem if local production is not stimulated. Currently however, poor dietary habits are believed to contribute to the increasing problems of diabetes and hypertension, though no reliable statistics are available for confirmation.

The major causes of morbidity and mortality are circulatory disorders, diabetes mellitus, malignant neoplasms and mental ill health, including substance abuse. Accidents and minor infections also make considerable demands on both the private and public health sectors. These diseases/conditions account for approximately 70 % of all deaths. Possible explanations for this trend may include poor general dietary habits, poor diets before and during pregnancy and fetal development, high levels of immunization coverage, sedentary lifestyles, as well as the presence of stress-inducing factors.

Epidemiological Trends

The BVI have a health situation, which reflects that of the rest of the Caribbean region, in terms of the similarity of health problems that have emerged. These include the increasing incidence and prevalence of non-communicable chronic diseases, the resurgence of some communicable diseases and an increase in the incidence of illnesses due to external causes (violence and injury).

The territory has a relatively young population with an increasing incidence of chronic disease in adult life. The pattern of diseases has moved from communicable diseases, especially those of childhood, to chronic non-communicable diseases and conditions that can be prevented by the adoption of healthy lifestyles in early life. The major causes of morbidity and mortality are hypertensive diseases, diabetes mellitus, malignant neoplasm (particularly breast, prostate, and cervical), bronchial asthma, arthritis and mental ill health, including substance abuse. These diseases account for over 70 % of all deaths. Possible explanations for this trend may include poor general dietary habits, poor diets before and during pregnancy and fetal development, early malnutrition, high levels of immunization coverage, as well as the presence of stress-inducing factors.

Accidents and minor infections make considerable demands on both the private and public health sectors. The territory has also seen the resurgence of some communicable diseases such as dengue fever, and respiratory tract infections. Communicable diseases usually associated with poverty and poor environmental conditions (tuberculosis and gastroenteritis) are also on the rise. There is also an increase in the prevalence of sexually transmitted diseases, and particularly HIV/AIDS.

Mortality and Morbidity

Deaths that occur in hospitals are certified by a medical practitioner and reported to the National Registration Office, while those that occur at home are reported by district registrars. Given the small population size it is important to treat mortality statistics with some caution. Small variation in actual figures each year may represent large changes in rates per thousand.

The crude death rate fluctuated during the period 1991 to 1995, from low of 4.3 per 1,000 in 1991 to 5.4 and 5.5 per 1,000 in 1992 and 1994 respectively. It showed a slight decline to 4.5 in 1995. It is likely that the next few years will see some increase in death rates as the proportion of the elderly population increases. A quarter of the number of deaths occurs in persons 80 years and over.

The infant mortality rate is subject to considerable variation due to the small denominator of live births. After 1987, infant deaths have numbered from 7 in 1987 to 4 in 1996 and infant mortality ratio in 1987 was 27.0 per 1000 live births. Increases of infant mortality rates were observed in 1987 and 1989, although the general trend was downward. Infant mortality fluctuated between a high of five deaths in 1991 and a low of one death in 1995. In 1991 - 1995, of 1,512 total births, 21 were stillbirths. Of the 1,491 live births, there were 19 infant deaths, 16 (84.2 %) of which occurred in the neonatal period. In the same five-year period, there were seven deaths in children 1 – 4 years old. These data can be translated into the following average annual rates for the period: stillbirth rate per 1,000 live births, 13.8, neonatal mortality rate per 1,000 live births, 10.7 and infant mortality rate per thousand live births, 12.74. There were four infant deaths in 1996.

During 1991-1995 there were two maternal deaths, one in 1993 and one in 1994. Both of which were due to complications in ectopic pregnancies resulting in a maternal mortality rate of 13.39 per 10,000 live births for the period.

There were 405 total deaths from all causes (including ill-defined conditions) during the period 1991-1995 as shown in table

Table 2 
Demographic Indicators 1980, 1991, 1995 and 1996.

Indicator	1980	1991	1995	1996
Crude Mortality Rate	7.1	4.6	4.5	4.6
Infant Mortality Rate	44.1	23.1	3.5	13.9
Dependency Ratio	67.0	49.0	47.8	47.6
Life Expectancy	69.0	74.60	74.6	74.8
Total Fertility Rate	2.8	1.9	1.8	1.9
Source: Development Planning Unit and Health Department

Table 3 
Principal Causes of Mortality in 1991 to 1995

Cause of Death	Number	%
Heart Disease	102	25.2
Malignant Neoplasm/Cancer	87	21.5
Cerebrovascular Diseases	42	10.4
Accidents/Injuries	35	8.6
Pneumonia/Bronchopneumonia	17	4.2
Perinatal Conditions	16	4.0
Diabetes Mellitus	9	2.2
AIDS	9	2.2
Renal failure	7	1.7
Alcoholism	4	0.9
Ill-defined causes	77	19.0
TOTAL	405	100.0
Source: Hospital Medical Records

Mortality data for 1991-1995 show that Non-Communicable Chronic Diseases have been the leading cause of death accounting for approximately 60 % of all deaths. In particular heart diseases, malignant neoplasm and cerebrovascular diseases have ranked in the top three positions. Accidents and injuries are also major causes of death. The main implications for this trend is that factors such as affluence, the aging process and lifestyles may be contributing agents.

Although more than 50% of the territory’s population is estimated to seek medical care from private physicians, available data on morbidity are from public facilities, and do not show morbidity at private clinics. Morbidity data is routinely collected at Peebles Hospital and summarized according to ICD classifications. Health centre and hospital data indicate that acute respiratory infections, dermatological problems, and gastroenteritis are important causes of morbidity among children. Mental disorders and injuries stand out among adolescents and adults; and circulatory disorders (hypertension, ischaemic heart diseases, congestive heart failures), diabetes mellitus, and degenerative diseases are major causes of ill health among the elderly.

Table 4 
Principal Causes of Morbidity (Hospitalization) in 1996

There have been no major outbreaks of communicable disease in the BVI in the last eight years.

• Vaccine Preventable Diseases: The Expanded Programme of Immunization covers six diseases: diphtheria, poliomyelitis, pertussis, whooping cough, measles and tuberculosis. During the last years there have been no cases of vaccine preventable diseases. Of the target population in 1996, 292 infants (from 0-12 months), 100 % received a full course of DPT, three dozes of oral trivalent poliomyelitis vaccine and MMR (measles, mumps and rubella)vaccine. Coverage for BCG was also 100%.
  
• Vector Borne Diseases: No cases of malaria or yellow fever have been reported in the last 10 years. Sporadic cases of dengue occur. In late 1995 to the first quarter of 1996, 37 cases were reported. Since then, a few isolated cases were reported. There was no reported case of leptospirosis, plague or encephalitis.
  
• Respiratory Infections: Acute respiratory infection is a major cause of admission to hospital of children under 15 years. In 1996, 32 (71.1%) out of 45 patients were under five years. There were no deaths from bronchopneumonia in this age group.

Seven cases of tuberculosis were reported during 1992-1996. Three of these cases were reported in 1996.

• Enteric Diseases: Gastroenteritis is identified as a major cause of morbidity in children. This condition was a major cause for persons seeking care in the emergency room in 1996. There was one death from gastroenteritis in 1996 and no deaths from this cause in the previous two years. Hospital admissions for gastroenteritis show a general increase from 1990 to 1996. There were no cases from 1990 to 1994, 3 in 1995 and 47 in 1996. There has been no case of typhoid since before 1981. One case of viral hepatitis was reported in 1995. Food poisoning is uncommon except for illness of ciguatera, of which there was an average of 22 admissions over the last three years. The food handler’s and immigration clinics revealed thirty-six positive tests for helminths from an attendance in 1996 of 1,412 and 1,116 respectively. No cases of cholera have been reported
  
• Sexually Transmitted Diseases: Data relating to sexually transmitted diseases gives an inaccurate picture of STD situation as many infected persons are treated by private practitioners who are reluctant to report cases. The ready access and utilization of service in the US Virgin Islands and other places to preserve anonymity further exacerbates the problem. Between 1985 and December 1997, 47 persons were reported as being HIV-positive. Of this number, 19 were reported as having full-blown AIDS; 15 of whom have since died. The male to female ratio among the 19 AIDS case was 2.1:1. Heterosexual transmission was the major route of infection with 16 (84%) cases assigned to this category. A recent HIV sero-prevalence study conducted in February 1996 to August 1997 revealed no positive HIV cases among the 408 pregnant women tested. Recent data on other STDs are not readily available.

The following statistics are based on data over three years 1994-1996:

After mental illness, diseases of the cardiovascular system and diabetes mellitus are the most common causes of hospitalization in the BVI. Cardiovascular disease, including ischemic heart disease, acute myocardial infarction, cerebrovascular accident (stroke) is the most frequent cause of death. The leading causes of death, all ages are: acute myocardial infarction, other diseases of the circulatory system, malignant neoplasm, cerebrovascular disease, pneumonia other diseases of the respiratory system.

Hospital morbidity statistics reinforce the conclusion that cardiovascular disease, cancer and diabetes mellitus are important health problems in the territory. Cardiovascular disease encompasses several different diseases of the circulatory system, including ischaemic heart disease, cerebrovascular disease, hypertensive disease, chronic rheumatic heart disease, and other forms of heart disease. Since 1993, admissions for cardiovascular diseases have gradually increased from 102 in 1993 to 113 in 1994 and 159 in 1996 accounting for 10% of admissions in 1996 ; while cancer accounted for 3% of admissions and diabetes mellitus 5%.

There were 77 admissions for diabetes mellitus in 1993, 59 in 1994, 68 in 1995 and 60 in 1996. The percentage of admissions during this period was 3.5% to 7%. In 1996 there were approximately 350 registered diabetics attending government clinics.

• Mental Health: Mental ill health is a cause of considerable morbidity in the BVI. The number of active patients attending the mental health clinic in 1996 was 200. Adult male accounted for 79 and female 105. There was a total of 16 children. In 1996, fifty- six of sixty- two hospital admissions for psychotic conditions were classified as drug induced (marijuana and crack cocaine) psychoses. 44 or 78.5% were between the ages 15-44, 38 were males and 6 were females. Admissions for other mental conditions were: schizophrenia 15, dementia 5, personality disorders and anxiety and stress reaction disorders 24. Alcohol abuse resulted in 55 admissions, 47 males and 7 females.
  
• Accidents and Trauma: Accidents contribute considerably to both mortality and morbidity in the British Virgin Islands. In particular, a toll is taken on active men aged 15-64 years. Of the 38 deaths analyzed in 1991-1995, 33(86.8%) were males of which twenty were under the age of 40. Eighteen deaths were due to drowning, seven to motor vehicle accidents, and gunshot (homicide) 6 from among the 38 deaths analyzed. Hospital statistics also revealed 17 admissions due to motor vehicle accidents in 1996.

Table 5 
Accidents and Trauma 1991 to 1995

Specific Health Problems

Analysis by Population Groups

1. Maternal and Child Health

The delivery of prenatal care forms a considerable part of private medical practice. About 25% of pregnant women receive antenatal care at the Government clinics. Most pregnant women make their first attendance during the second trimester. The vast majority of deliveries (about 98%) take place in hospital. Hospital delivery is actively encouraged and mothers from the out islands come into the hospital at Road Town.

Based on hospital statistics for 1995-1996, 8% of deliveries is to mothers aged 15-19 years. Within this group, the majority of births were to mothers over 18 years. Pregnancy under 15 years is infrequent. There were two maternal deaths due to ruptured ectopic pregnancies. One occurred in 1993 and one in 1994.

Admissions to the hospital for spontaneous abortions account for 2-3%, a gradually increasing trend. The number in 1995 was 39 compared to 55 in 1996. Pelvic inflammatory diseases and other gynecological conditions are important causes of morbidity resulting in 4-5% of total admissions annually.

During the period 1990 to 1995 approximately 28% of infants born were considered high risk births because of low Apgar score, multiple births, cesarean sections, low birth weight, and prematurity.

Of the 19 total infant deaths in 1991-1995, 84.2% (16) occurred during the neonatal period. The leading cause of morbidity for children under 5 years was perinatal conditions with 42 admissions, acute respiratory infection ranked second with 38 admissions. These were followed by drowsiness (35), bronchopneumonia (31), diarrhoea and gastroenteritis (27), asthma (25), convulsions and head injuries (25) and inguinal hernia (18).

The main health problems in children under 5 years old at health centres/clinics were skin rashes and skin infections, allergic reactions, gastroenteritis, obesity, and acute respiratory tract infection.

The nutrition status (Caribbean standard) among children under 5 years old attending child health clinics in 1991-1995 were: severe malnutrition 0%; mild to moderate malnutrition 2%; normal 77%; obesity 21%. As is shown in this profile, although there are no cases of severe malnutrition, there is the tendency to overfeed children resulting in obesity.

The school-age population (5 - 16 years old) including pre-primary, primary and secondary schools was 3,681 in 1990. The main health problems among pre-primary and primary students are dental caries, skin rashes and/or infections, allergic reactions, and minor injuries. Problems affecting high school students are injuries, fevers, coughs and colds, allergic reactions, and dysmenorrhea.

Data from the 1991 census revealed that 4.4% (716) of the population had one form of disability or another. Of this proportion, 4.6% reported mental retardation, 12.6%, 3.1% and 2.9% indicated sight, hearing and speech impediments respectively. "Other impairments were reported by 62.2%".

In 1996, there were 2,230 visits at Family Planning Clinics by 1654 clients (32.4 % of the female population aged 15-44 years). Approximately 47% were on oral contraceptive pills and just over 25% on injectable contraceptives. Twenty-six thousand (26,000) condoms were issued, 6.5% of clients were aged 15-18 years. During this period, 277 Pap smears were taken 17 were abnormal, of these 5 required further medical intervention.

2. Adolescent and Adult Health

Mental disorders occurring among adolescents and adults are mainly related to substance abuse psychoses, and account for a high percent of hospital admissions. Injuries related to falls, boat and motor vehicle traffic accidents are also common.

Mental disorders, particularly among those aged 25- 44 years old, ranked highest for hospital admissions from 1991 to 1995. Diabetes, hypertension, injury, heart disease, and complications related to pregnancy are other leading causes of morbidity. In 1991, mental disorders were the leading cause of hospitalization in Peebles Hospital, with 129 admissions. Pregnancy complications ranked second with 74 admissions, followed by diabetes mellitus with 69, heart diseases with 61, hypertension with 52, and fractures/open wounds with 47 admissions. Asthma and concussion also were important with 25 and 21 admissions respectively. It should be noted that patients of all ages are included in these numbers.

Over the period 1990 to 1996, of the total live births, births to teenage mothers ranged from a low of 6.25% in 1990 to a high of 11.38% in 1992. The average age of teenage girls giving birth has been 18 years from 1990 to 1996 inclusive. The average age of women aged 15 - 44 years old giving birth over this period was 27.3 years. Family life education and family planning services are available to teenage girls.

Hypertension and diabetes continue to be the main causes of morbidity, particularly in the age group 45 years old and older: 72% of persons with hypertension admitted to hospital and 80% of persons with diabetes were 45 years old and older. Cerebrovascular disease associated with hypertension is a leading cause of mortality. The main reasons for hospitalization of diabetes are for stabilization and for treatment of infections, especially those of the upper respiratory tract.

The rise in deaths from accidents and injury mainly affects the young and economically active population. The rates peak in the 20-40 age group, but remain constant thereafter. For the age group 15-44, injury was the leading cause of death during 1991 to 1995.

Data on communicable diseases and sexually transmitted diseases show that the highest mortality rates for the former are among the very young and the very old, whilst for the latter, the highest rates are borne in the 15-29 age-group

3. Health of the Elderly

There is a close correlation between age and the non-communicable diseases previously discussed. Mortality rates for circulatory disorders (especially heart diseases) and neoplasms in particular, drastically increase by age 45, and in the age-group 45-64 the rates are 6 to 12 times the preceding age group. By age 65 and over they are 26-70 times the rate of the 25-44 age group. It is necessary, however, to examine and separate the effect of aging from the consequences of exposure to a range of other risk factors.

The main causes of mortality and chronic ill health in this group are cardiovascular and cerebrovascular diseases and malignant neoplasms. Arthritis and osteoarthritis are common causes of hospitalization. 

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