A Research Agenda to Inform Cannabis Regulation: How Science Can Shape Policy.

In the United States, changes to cannabis policy have outpaced scientific knowledge about cannabis, its effects, and the impacts of different policy approaches. Research barriers stem from key federal policies, including strict drug scheduling of cannabis, which comprehensively hinder the ability to conduct cannabis research, affecting state markets, evidence-based regulation, and scientific gains that could more effectively shape policy moving forward. The Cannabis Regulators Association (CANNRA) is a nonpartisan nonprofit organization that convenes and supports government agencies to facilitate information exchange and learning from existing cannabis regulations across US states and territories and other governmental jurisdictions. This commentary outlines a research agenda that, if implemented, would address critical gaps in the science that cannabis regulators have identified in terms of knowledge regarding: (1) medicinal use of cannabis; (2) cannabis product safety; (3) cannabis consumer behaviors; (4) policies to promote equity and reduce disparities, both in the industry and more broadly in communities affected by the past criminalization of cannabis; (5) policies to prevent youth consumption and promote public health and safety; and (6) policies to reduce the illicit market and associated harms. The research agenda outlined here is the result of both formal discussions through CANNRA-wide meetings and informal discussions cannabis regulators have had as part of CANNRA committees. This research agenda is not all encompassing but rather highlights areas of research that have vital importance for cannabis regulation and policy implementation. Although many organizations weigh in on research needs related to cannabis, cannabis regulators (ie, the individuals implementing policies legalizing cannabis in states and territories) have generally not had a voice at the table advocating for specific research to be conducted. Their perspective representing the government agencies closest to the ground in terms of experiencing the impacts of current cannabis policy is essential to furthering quality, practical research that can advance informed and effective policy.

Prevention of community-associated methicillin-resistant Staphylococcus aureus infection among Asian/Pacific Islanders: a qualitative assessment.

BACKGROUND: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has been increasingly reported over the past decade, including in Asian/Pacific Islanders (A/PIs). METHODS: We conducted ethnographic interviews in O'ahu and Kaua'i, Hawai'i, with 10 Asian/Pacific Islanders identified as having a history of CA-MRSA infections. RESULTS: Most (7/10) thought skin infections were not a new problem in Hawai'i. Most (8/9) attempted to self-treat the infection prior to seeking medical care with a range of home remedies and store- bought solutions. Most respondents did not initially comprehend the severity of their infection and only sought medical treatment after concern from family, unbearable pain, and/or other symptoms of illness. CONCLUSION: Clinicians should be aware of the reportedly frequent use of home remedies by this population, as it may potentially contribute to interactions when treatments are combined. If clinicians and public health professionals do not address perceptions and misperceptions of how MRSA is acquired, it will be very difficult to prevent infection, and may also delay individuals from seeking treatment.

Leptospirosis on Oahu: an outbreak associated with flooding of a university campus.

On October 31, 2004, a stream overflowed, flooding the University of Hawaii (UH) campus. On November 19, 2004, a possible flood-related leptospirosis case (Patient 1) was reported to the Hawaii State Department of Health (HDOH). Surveillance for febrile illness was established through an Internet questionnaire. Active case finding was conducted among groups involved in the flood clean-up. Free leptospirosis testing was offered by HDOH. Patient 1's illness was confirmed as leptospirosis by microscopic agglutination testing. A total of 271 persons responded to the Internet survey, of whom 90 (33%) reported a febrile illness within 30 days of contact with flood water. Forty-eight respondents (18%) were tested for leptospirosis. One additional acute leptospirosis case was identified. Patient 2 was epidemiologically linked to Patient 1. Health care providers should maintain a high level of suspicion for leptospirosis after flooding events, and local public health officials should promote leptospirosis awareness among flood-affected populations.

Isolate removal methods and methicillin-resistant Staphylococcus aureus surveillance.

The effect of duplicate isolate removal strategies on Staphylococcal aureus susceptibility to oxacillin was compared by using antimicrobial test results for 14,595 isolates from statewide surveillance in Hawaii in 2002. No removal was compared to most resistant and most susceptible methods at 365 days and to the National Committee for Clinical Laboratory Standards (NCCLS) and Cerner algorithms at 3-, 10-, 30-, 90-, and 365-day analysis periods. Overall, no removal produced the lowest estimates of susceptibility. Estimates with either NCCLS or Cerner differed by <2% when the analysis period was the same; with either method, the difference observed between a 90- and a 365-day period was <1%. The effect of duplicate isolate removal was greater for inpatient than outpatient settings. Considering the ease of implementation and comparability of results, we recommend using the first isolate of a given species per patient to calculate susceptibility frequencies for S. aureus to oxacillin.

Methicillin-resistant Staphylococcus aureus, Hawaii, 2000-2002.

The emergence of methicillin-resistant Staphylococcus aureus (MRSA) has generated considerable concern among medical and public health professionals. We used a statewide, population-based antimicrobial resistance surveillance system to examine epidemiologic trends for MRSA from outpatients and inpatients in Hawaii. Pediatric and adult patient populations were compared to assess characteristics of MRSA isolates specific for each group. From 2000 to 2002, 8,206 (26%) of 31,482 total S. aureus isolates were MRSA. During this period, the proportion of MRSA isolates increased in both outpatient and inpatient clinical settings (p<0.01). When stratified by age, annual trends showed a significant increase in the proportion of MRSA in adult patients (from 24% to 30%, p<0.01) but not in pediatric patients (from 25% to 27%, p>0.05). Although MRSA isolates from adults demonstrated high resistance to most non-beta-lactams, most MRSA isolates from pediatric outpatients remained susceptible to most non-beta-lactams.

Dengue fever, Hawaii, 2001-2002.

Autochthonous dengue infections were last reported in Hawaii in 1944. In September 2001, the Hawaii Department of Health was notified of an unusual febrile illness in a resident with no travel history; dengue fever was confirmed. During the investigation, 1,644 persons with locally acquired denguelike illness were evaluated, and 122 (7%) laboratory-positive dengue infections were identified; dengue virus serotype 1 was isolated from 15 patients. No cases of dengue hemorrhagic fever or shock syndrome were reported. In 3 instances autochthonous infections were linked to a person who reported denguelike illness after travel to French Polynesia. Phylogenetic analyses showed the Hawaiian isolates were closely associated with contemporaneous isolates from Tahiti. Aedes albopictus was present in all communities surveyed on Oahu, Maui, Molokai, and Kauai; no Ae. aegypti were found. This outbreak underscores the importance of maintaining surveillance and control of potential disease vectors even in the absence of an imminent disease threat.

Low risk of measles transmission after exposure on an international airline flight.

In May 2000, a passenger with measles traveled aboard a 7-hour flight from Japan to Hawaii. A follow-up survey was sent to 307 (91%) of the 336 exposed passengers to identify susceptible passengers and subsequent occurrences of measles. The median age of the 276 respondents (90%) was 34 years; 268 (97%) were residents of Japan. Self-reports determined that 173 (63%) were immune through prior measles or vaccination; 6 (2%) denied a history of prior measles or immunization, and 97 (35%) were unaware of their status. Only 1 nonimmune respondent received immunoprophylaxis. None of the respondents developed a febrile rash illness 7-21 days after exposure. The risk of in-flight measles transmission among passenger populations with similar susceptibility profiles appears to be low. An aggressive response by health departments may not be warranted after airborne exposure to measles. Each health department should make such determinations on the basis of specific circumstances and availability of resources.

Enhancing public health surveillance for influenza virus by incorporating newly available rapid diagnostic tests.

Beginning with the 1999-2000 influenza season, physicians throughout Hawaii ordering a viral culture for patients with suspected influenza were also offered influenza rapid testing. We compared the number of viral respiratory cultures sent to the Hawaii Department of Health and the number of providers who participated in influenza surveillance over consecutive influenza seasons. The number of viral respiratory cultures rose from 396 to 2,169 between the 1998-1999 and 2000-2001 influenza seasons, and the number of providers submitting >1 influenza culture increased from 34 to 327, respectively. The number of influenza isolates obtained each season also increased (from 64 to 491). The available data suggest that the changes observed in Hawaii's influenza surveillance were not secondary to differences in influenza activity between seasons. This is the first evaluation of integrating influenza rapid testing into public health surveillance. Coupling rapid tests with cultures appears to be an effective means of improving influenza surveillance.