One response: Global Outbreak Alert and Response Network supporting the COVID-19 response, Kiribati.

Problem: In January 2022, Kiribati experienced widespread community transmission of COVID-19, leading to high rates of infection among health-care workers (HCWs), which reduced essential HCWs during a period of increased hospital admissions. Context: Kiribati, a Pacific island country made up of a remote group of 33 low-lying atolls in the Pacific Ocean, experienced its first surge of COVID-19 cases beginning on 24 January 2022. Action: Reports of increasing numbers of COVID-19 cases in South Tarawa prompted the Kiribati Ministry of Health and Medical Services to request assistance from the international community, including the World Health Organization's Global Outbreak Alert and Response Network (GOARN), to support national COVID-19 response operations. Specialists in infection prevention and control (IPC) were deployed to Kiribati in February 2022 to assist the Ministry's National COVID-19 Taskforce in collaboration with national partners. These specialists helped review and strengthen IPC capacities to accommodate a potential patient surge and consequent demands for medical consumables in health-care facilities in South Tarawa. Outcome: Strengthened knowledge about and processes for IPC among HCWs prevented health care-associated infections and reduced community disease transmission during the first surge of COVID-19 cases in Kiribati. Discussion: GOARN has the capacity and ability to rapidly deploy experts to support requests for assistance. Outbreak response activities can be enhanced and sustained by using GOARN's resources and collaborating with all partners, as necessary.

Characterizing Family Planning Utilization in Adult Women and Adolescents in Pohnpei, Federerated States of Micronesia.

INTRODUCTION: Increasing family planning xutilization in low-income countries to improve health outcomes of women and children is a global priority. The Federated States of Micronesia (FSM) has poor maternal child health outcomes; therefore, this study aimed to examine family planning utilization in Pohnpei State, FSM. METHODS: This cross-sectional study sought to characterize family planning utilization in adult women of reproductive age and high school age adolescents in Pohnpei using representative survey data collected in 2019 (N = 570 and N = 1726, respectively). Chi-square tests were used to determine significant factors associated with family planning utilization. RESULTS: Among adult women of reproductive age (18-49 years old) not trying to get pregnant, 31.6% reported using contraception during last intercourse. Contraceptive use was significantly lower among younger women (18-24 years old) (21.7%, p = 0.021), unmarried women (18.6%, p < 0.001), those without health insurance (28.7%, p = 0.030), those who have never had a pap smear (20.5%, p < 0.001), and those who have never been pregnant (14.5%, p < 0.002). Among adolescents who reported being sexually active, 28.5% reported using any contraception at last intercourse and 22.6% reported using a condom at last intercourse. Condom use among sexually active adolescents was lowest among 12th graders (13.5%, p < 0.001) and girls (16.8%, p = 0.004). CONCLUSIONS: Our findings suggest that young, unmarried, never pregnant women face an unmet need for family planning. Additionally, women with lower access to and use of healthcare services have lower use of family planning.

Hepatitis B virus infection on Kwajalein Atoll, Marshall Islands: a seroprevalence, knowledge and attitudes study.

Objective: A study was conducted to determine the seroprevalence of chronic hepatitis B virus (HBV) infection among children and their mothers on Kwajalein Atoll in the Marshall Islands two decades after routine vaccination was introduced in the 1990s. Mothers' knowledge and attitudes towards HBV disease and vaccination were also assessed. Methods: Results of a national seroprevalence survey conducted in 2016-2017 and antenatal records were used to determine the prevalence of HBV seropositivity in children aged 6-8 years and their biological mothers. The associations between demographic, social and vaccination-related factors and seropositivity were explored using Fisher's exact tests. Results: HBV seroprevalence was 0.3% in children and 6.8% in their mothers (during pregnancy). Coverage of timely HBV vaccination was 90.3% for the birth dose and was significantly associated with factors related to place of residence (P < 0.001), place of birth (P < 0.001) and number of antenatal visits (P < 0.001). Maternal attitudes towards infant vaccination and antenatal screening were largely positive (95.8% and 96.7%, respectively) despite low vaccination rates (20.9%) among mothers. Knowledge levels were low for disease complications, treatment and transmission. Discussion: Prevalence of HBV in children and mothers residing on Kwajalein Atoll in 2016-2017 was lower than the national average for the Marshall Islands. Timely birth dose administration appears to have been effective in preventing mother-to-child transmission of HBV in this setting and should be promoted in remote settings where antiviral therapy is not available. Provision of out-of-cold-chain HBV vaccines should be considered to improve access in remote settings.

Decolonising Environmental Risk Assessments of Potentially Polluting Wrecks: a Case Study of the Wreck of the USS Mississinewa in Ulithi Lagoon, Federated States of Micronesia.

Millions of tonnes of oil lie entombed within wrecks from two world wars which, when released, can cause environmental devastation. Wrecks are predominantly risk assessed by the Global North Nations responsible, resulting in an epistemology that separates human from nature. This research aimed to decolonise risk assessments to capture the spatially heterogeneous nature of human vulnerability to oil pollution. Triangulation analysis of interviews and official reports relating to the USS Mississinewa oil spill identified three Global South issues a Eurocentric risk assessment failed to capture: region-specific meteorological conditions causing the leak, remoteness making external resources slow to arrive, and the impact of the fishery closure on traditional subsistence lifestyles. A vulnerability assessment is proposed to prioritise wrecks in susceptible locations. Recommendations are made for a collaborative approach to wreck management by including local voices, resisting the Global North assumption of generality, and recognising the priorities of those living with wrecks.

Migration, belonging, and the sustainability of atoll islands through a changing climate.

Climate change might catalyze and exacerbate the trend of outmigration from low-lying atoll islands. There is speculation that migration away from atolls may not stop until such islands are abandoned. Yet migration creates both opportunities and risks for the sustainability of atoll communities. There is a trade-off between reduced demographic pressure on increasingly fragile atoll island environments and the financial and human resources necessary to adapt to climate change that can result from migration. Here we propose and analyze belonging as the centripetal force that makes migration a process that enhances the sustainability of atoll populations. We examine the relationship between migration, belonging, and the sustainability of populations on atoll islands based on data collected in three atoll islands in the Pacific: the island state of Niue; Namdrik Atoll in the Republic of the Marshall Islands; and Budibudi atoll (Laughlan Islands) in Papua New Guinea. In each case, belonging binds the people who live in and migrate from these places into a collective commitment to their continuity, yet it does so to different degrees according to the economic opportunities available to migrants and the infrastructure that enables extended communities to remain connected.

Assessment of diabetes self-care behaviors and knowledge among Marshallese adults with type 2 diabetes in the Republic of the Marshall Islands.

AIMS: The aim of this study is to assess and document engagement in type 2 diabetes mellitus (T2DM) self-care behaviors and self-reported diabetes knowledge among Marshallese adults living in the Republic of the Marshall Islands (RMI). METHODS: The study uses data from a T2DM health screening study completed in the RMI; survey and biometric data were captured as part of the health screenings. Study objectives were examined using descriptive statistics to describe the characteristics of the participants, their diabetes self-care behaviors, and their levels of self-reported diabetes knowledge. RESULTS: Results indicate many Marshallese diagnosed with T2DM did not engage in adequate self-care behaviors, including blood sugar checks and foot examinations. Participants reported having forgone needed medical care and medication due to issues with cost and/or access, and participants reported low levels of diabetes knowledge. CONCLUSIONS: The results demonstrate the need for further work in improving engagement in diabetes self-care by Marshallese living in the RMI. Increased engagement in self-care and diabetes education programs may help Marshallese with T2DM to improve control of their glucose and avoid long-term health complications, as well as reduce costs to the healthcare system.

Microplastics absent from reef fish in the Marshall Islands: Multistage screening methods reduced false positives.

Island communities, like the Republic of the Marshall Islands (RMI), depend on marine resources for food and economics, so plastic ingestion by those resources is a concern. The gastrointestinal tracts of nine species of reef fish across five trophic groups (97 fish) were examined for plastics >1 mm. Over 2100 putative plastic particles from 72 fish were identified under light microscopy. Only 115 of these from 47 fish passed a plastic screening method using Fourier-transform infrared microspectroscopy (µFTIR) in reflectance mode. All of these were identified as natural materials in a final confirmatory analysis, attenuated total reflectance FTIR. The high false-positive rate of visual and µFTIR methods highlight the importance of using multiple polymer identification methods. Limited studies on ingested plastic in reef fish present challenging comparisons because of different methods used. No plastic >1 mm were found in the RMI reef fish, reassuring human consumers.

Exploring the link between home garden use and severe obesity: Insights from a nationwide survey in Tuvalu.

Background: Obesity is prevalent and increasing but understudied across Pacific Islanders. Tuvalu is a South Pacific country with a high obesity rate and faces multiple threats of food insecurity. Home garden serves as a sustainable food source and can be a possible intervention for the obesity pandemic in Tuvalu. This study investigated Tuvaluans' home garden use and obesity, and explored factors associated with increased use of home gardens. Methods: We conducted a nationwide, cross-sectional study in Tuvalu during 2022. Structured questionnaires were administered during the in-person interviews, and trained interviewers measured the height and weight of each participant. The association between home garden use, obesity and severe obesity were tested with univariate and multivariable logistic regression. We also applied overlapping weights to balance the distribution of baseline demographic factors. Results: The average body mass index was 34.87 kilogrammes (kg) / square metre (m2) among the study population of 1024 adults (630 from Funafuti and 394 from other islands in Tuvalu). Overall, people having home gardens was associated lower odds for severe obesity compared to those without a home garden in overlap weighting models (odds ratio (OR) = 0.946, 95% CI = 0.897-0.997, P = 0.039) and the association was stronger in Funafuti (OR = 0.927, 95% CI = 0.866-0.991, P = 0.027) than in the outlying islands (OR = 0.967, 95% CI = 0.889-1.052, P = 0.435). Furthermore, increased age was positively associated with having a home garden in Funafuti, and smoking showed an inverse association. Conclusions: Having a home garden is associated with lower odds of severe obesity in Tuvalu, and the association is stronger in Funafuti. Smokers are less likely to have home gardens, and increased age is positively associated with having home gardens. These findings promote more home garden utilisation and provide evidence for targeted interventions in Tuvalu.

Molecular characterization and geographical distribution of Zika virus worldwide from 1947 to 2022.

OBJECTIVES: We conducted molecular characterization, demonstrated the geographical distribution of Zika virus (ZIKV) circulating worldwide from 1947 to 2022 and explored the potential genetic recombination site in the Thailand ZIKV genomes. METHODS: We constructed phylogenetic trees based on ZIKV coding sequences (CDS) and determined the geographical distribution of the representative viruses by genetic relationship and timeline. We determined genetic recombination among ZIKV and between ZIKV and other flaviviruses using similarity plot and bootscan analyzes, together with the phylogeny encompassing the CDS and eight subgenomic regions. RESULTS: The phylogenetic trees comprising 717 CDS showed two distinct African and Asian lineages. ZIKV in the African lineage formed two sublineages, and ZIKV in the Asian lineage diversified into the Asian and American sublineages. The 1966 Malaysian isolate was designated the prototype of the Asian sublineage and formed a node of only one member, while the newer viruses formed a distinct node. We detected no genetic recombination in the Thailand ZIKV. CONCLUSION: Five Thailand isolates discovered in 2006 were the second oldest ZIKV after the Malaysian prototype. Our result suggested two independent routes of ZIKV spread from Southeast Asia to Micronesia in 2007 and French Polynesia in 2013 before further spreading to South American countries.

Changes in trachoma indicators in Kiribati with two rounds of azithromycin mass drug administration, measured in serial population-based surveys.

Baseline mapping in the two major population centers of Kiribati showed that trachoma was a public health problem in need of programmatic interventions. After conducting two annual rounds of antibiotic mass drug administration (MDA), Kiribati undertook trachoma impact surveys in 2019, using standardized two-stage cluster surveys in the evaluation units of Kiritimati Island and Tarawa. In Kiritimati, 516 households were visited and in Tarawa, 772 households were visited. Nearly all households had a drinking water source and access to an improved latrine. The prevalence of trachomatous trichiasis remained above the elimination threshold (0.2% in ≥15-year-olds) and was virtually unchanged from baseline. The prevalence of trachomatous inflammation-follicular (TF) in 1-9-year-olds decreased by approximately 40% from baseline in both evaluation units but remained above the 5% TF prevalence threshold for stopping MDA. TF prevalence at impact survey was 11.5% in Kiritimati and 17.9% in Tarawa. Infection prevalence in 1-9-year-olds by PCR was 0.96% in Kiritimati and 3.3% in Tarawa. Using a multiplex bead assay to measure antibodies to the C. trachomatis antigen Pgp3, seroprevalence in 1-9-year-olds was 30.2% in Kiritimati and 31.4% in Tarawa. The seroconversion rate, in seroconversion events/100 children/year, was 9.0 in Kiritimati and 9.2 in Tarawa. Seroprevalence and seroconversion rates were both assessed by four different assays, with strong agreement between tests. These results show that, despite decreases in indicators associated with infection at impact survey, trachoma remains a public health problem in Kiribati, and provide additional information about changes in serological indicators after MDA.

Effectiveness of population-wide screening and mass drug administration for leprosy control in Kiribati: the COMBINE protocol.

INTRODUCTION: Progress towards leprosy elimination is threatened by increasing incidence in 'hot-spot' areas where more effective control strategies are urgently required. In these areas, active case finding and leprosy prevention limited to known contacts is insufficient for control. Population-wide active case-finding together with universal prevention through mass drug administration (MDA) has been shown to be effective in 'hot-spot' areas, but is logistically challenging and expensive. Combining leprosy screening and MDA with other population-wide screening activities such as for tuberculosis may increase programme efficiency. There has been limited evaluation of the feasibility and effectiveness of combined screening and MDA interventions. The COMBINE study aims to bridge this knowledge gap. METHODS AND ANALYSIS: This implementation study will assess the feasibility and effectiveness of active leprosy case-finding and treatment, combined with MDA using either single-dose rifampicin or rifamycin-containing tuberculosis preventive or curative treatment, for reducing leprosy incidence in Kiribati. The leprosy programme will run over 2022-2025 in concert with population-wide tuberculosis screening-and-treatment in South Tarawa. The primary research question is to what extent the intervention reduces the annual leprosy new case detection rate (NCDR) in adults and children compared with routine screening and postexposure prophylaxis (PEP) among close contacts (baseline leprosy control activities). Comparisons will be made with (1) the preintervention NCDR separably among adults and children in South Tarawa (before-after study) and (2) the corresponding NCDRs in the rest of the country. Additionally, the postintervention prevalence of leprosy obtained from a survey of a 'hot-spot' sub-population will be compared with prevalence documented during the intervention. The intervention will be implemented in collaboration with the Kiribati National Leprosy Programme. ETHICS AND DISSEMINATION: Approval has been obtained from the Kiribati Ministry of Health and Medical Services (MHMS), the University of Otago (H22/111) and the University of Sydney (2021/127) Human Research Ethics Committees. Findings will be shared with the MHMS, local communities and internationally through publication.

Moderate chlorophyll-a environments reduce coral bleaching during thermal stress in Yap, Micronesia.

Thermal-stress events on coral reefs lead to coral bleaching, mortality, and changes in species composition. The coral reefs of Yap, in the Federated States of Micronesia, however, remained largely unaffected by major thermal-stress events until 2020, when temperatures were elevated for three months. Twenty-nine study sites were examined around Yap to determine geographical and taxonomic patterns of coral abundance, bleaching susceptibility, and environmental predictors of bleaching susceptibility. Island-wide, 21% (± 14%) of the coral cover was bleached in 2020. Although inner reefs had a greater proportion of thermally-tolerant Porites corals, the prevalence of bleaching was consistently lower on inner reefs (10%) than on outer reefs (31%) for all coral taxa. Corals on both inner and outer reefs along the southwestern coast exhibited the lowest prevalence of coral bleaching and had consistently elevated chlorophyll-a concentrations. More broadly, we revealed a negative relationship between bleaching prevalence and (moderate) chlorophyll-a concentrations that may have facilitated resistance to thermal stress by reducing irradiance and providing a heterotrophic energy source to benefit some corals exposed to autotrophic stress. Southwestern reefs also supported a high but declining fish biomass, making these bleaching-resistant and productive reefs a potential climate-change refuge and a prime target for conservation.

Faith-based health screenings for Marshallese adults living in the Republic of the Marshall Islands: Study design and results.

Introduction: Striking health disparities exist in the Republic of the Marshall Islands (RMI). The RMI has one of the highest age-adjusted type 2 diabetes mellitus (T2DM) rates in the world (23.0%) compared to global (9.3%) and United States (US; 13.3%) rates. We conducted health screenings including clinical indicators of T2DM and hypertension among Marshallese in the RMI. Methods: Screenings were conducted at 20 churches on Majuro Atoll. Participants completed questionnaires and biometric data collection assessing glycated hemoglobin (HbA1c), blood pressure, and body mass index. Results: Screenings included 528 participants and showed a high prevalence of T2DM, obesity, and hypertension. One-third of participants were referred to the non-communicable disease clinic. The percent of adults in this study with T2DM-indicative HbA1c (48.5%) is higher than observed at the national level (23.0%). Discussion: Results highlight the need for non-communicable disease-related programs in the RMI.

Tropical lacustrine sediment microbial community response to an extreme El Niño event.

Salinity can influence microbial communities and related functional groups in lacustrine sediments, but few studies have examined temporal variability in salinity and associated changes in lacustrine microbial communities and functional groups. To better understand how microbial communities and functional groups respond to salinity, we examined geochemistry and functional gene amplicon sequence data collected from 13 lakes located in Kiritimati, Republic of Kiribati (2° N, 157° W) in July 2014 and June 2019, dates which bracket the very large El Niño event of 2015-2016 and a period of extremely high precipitation rates. Lake water salinity values in 2019 were significantly reduced and covaried with ecological distances between microbial samples. Specifically, phylum- and family-level results indicate that more halophilic microorganisms occurred in 2014 samples, whereas more mesohaline, marine, or halotolerant microorganisms were detected in 2019 samples. Functional Annotation of Prokaryotic Taxa (FAPROTAX) and functional gene results (nifH, nrfA, aprA) suggest that salinity influences the relative abundance of key functional groups (chemoheterotrophs, phototrophs, nitrogen fixers, denitrifiers, sulfate reducers), as well as the microbial diversity within functional groups. Accordingly, we conclude that microbial community and functional gene groups in the lacustrine sediments of Kiritimati show dynamic changes and adaptations to the fluctuations in salinity driven by the El Niño-Southern Oscillation.

Family and Community Obligations Motivate People to Immigrate-A Case Study from the Republic of the Marshall Islands.

A questionnaire survey was conducted in the Marshall Islands among 308 citizens of Majuro in order to analyze the factors that led them to immigrate. Using the results from the questionnaire items that indicate the motivations for emigration as independent variables, we extracted the factors with significantly high correlation coefficients; they suggest that the desire to escape from the many obligations within the family and regional community are predominant push factors for migrating overseas while the economic disparity between the United State and their home countries are predominant pull factors. Independently, the Permutation Feature Importance was used to extract the salient factors motivating migration, which provides similar results. Furthermore, the result of structural equation modeling verified the hypothesis that an escape from many obligations and economic disparity is a major motivation for migration at a significance level of 0.1%.

Feasibility of Healthy Beverages Policies in American Samoa and Federated States of Micronesia: Water and Coconut Water Only Community Interventions.

American Samoa and the Federated States of Micronesia (FSM) are two small Pacific Island nations that have some of the highest noncommunicable disease (NCD) mortality rates in the world. Supported by church leaders to address obesity as an NCD risk factor, American Samoa, and Chuuk and Kosrae States of FSM selected the implementation of healthy beverages as a nutrition intervention through a water- and coconut water-only pledge in church events. The consumption of water and coconut water was tracked. Across 105 church events in the three jurisdictions, the count of water bottles before and after events decreased from 142.8 to 22.3, the number of coconuts before and after events decreased from 19.6 to 1.2, and cups of water before and after events decreased from 52.9 to 7.6. The promotion of healthy beverages in church settings holds promise in the Pacific as a feasible, accessible, and culturally responsive nutrition approach, given limited access to other nutritional alternatives, e.g., fresh fruits and vegetables. Supplemental health promotion messaging to maintain knowledge and attitudes about healthy is recommended for future scaling up.