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.

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.

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.

How the Commonwealth of the Northern Mariana Islands stalled COVID-19 for 22 months and managed its first significant community transmission.

Objective: The Commonwealth of the Northern Mariana Islands (CNMI) is a remote Pacific island territory with a population of 47 329 that successfully prevented the significant introduction of coronavirus disease (COVID-19) until late 2021. This study documents how the response to the introduction of COVID-19 in CNMI in 2021 was conducted with limited resources without overwhelming local clinical capacity or compromising health service delivery for the population. Methods: Data from COVID-19 case investigations, contact tracing, the Commonwealth's immunization registry and whole genome sequencing were collated and analysed as part of this study. Results: Between 26 March 2020 and 31 December 2021, 3281 cases and 14 deaths due to COVID-19 were reported in CNMI (case fatality rate, 0.4%). While notification rates were highest among younger age groups, hospitalization and mortality rates were disproportionately greater among those aged > 50 years and among the unvaccinated. The first widespread community transmission in CNMI was detected in October 2021, with genomic epidemiology and contact tracing data indicating a single introduction event involving the AY.25 lineage and subsequent rapid community spread. Vaccination coverage was high before widespread transmission occurred in October 2021 and increased further over the study period. Discussion: Robust preparedness and strong leadership generated resilience within the public health sector such that COVID-19 did not overwhelm CNMI's health system as it did in other jurisdictions and countries around the world. At no point was hospital capacity exceeded, and all patients received adequate care without the need for health-care rationing.

Study Protocol: Interactive Dynamics of Coral Reef Fisheries and the Nutrition Transition in Kiribati.

The Kiribati 2019 Integrated Household Income and Expenditure Survey (Integrated HIES) embeds novel ecological and human health research into an ongoing social and economic survey infrastructure implemented by the Pacific Community in partnership with national governments. This study seeks to describe the health status of a large, nationally representative sample of a geographically and socially diverse I-Kiribati population through multiple clinical measurements and detailed socio-economic surveys, while also conducting supporting food systems research on ecological, social, and institutional drivers of change. The specific hypotheses within this research relate to access to seafood and the potential nutritional and health benefits of these foods. We conducted this research in 21 of the 23 inhabited islands of Kiribati, excluding the two inhabited islands-Kanton Islands in the Phoenix Islands group with a population of 41 persons (2020 census) and Banaba Island in the Gilbert Islands group with a population of 333 persons (2020 census)-and focusing exclusively on the remaining islands in the Gilbert and Line Islands groups. Within this sample, we focused our intensive human health and ecological research in 10 of the 21 selected islands to examine the relationship between ecological conditions, resource governance, food system dynamics, and dietary patterns. Ultimately, this research has created a baseline for future Integrated HIES assessments to simultaneously monitor change in ecological, social, economic, and human health conditions and how they co-vary over time.

Population-wide active case finding and prevention for tuberculosis and leprosy elimination in Kiribati: the PEARL study protocol.

INTRODUCTION: Population-wide interventions offer a pathway to tuberculosis (TB) and leprosy elimination, but 'real-world' implementation in a high-burden setting using a combined approach has not been demonstrated. This implementation study aims to demonstrate the feasibility and evaluate the effect of population-wide screening, treatment and prevention on TB and leprosy incidence rates, as well as TB transmission. METHODS AND ANALYSIS: A non-randomised 'screen-and-treat' intervention conducted in the Pacific atoll of South Tarawa, Kiribati. Households are enumerated and all residents ≥3 years, as well as children <3 years with recent household exposure to TB or leprosy, invited for screening. Participants are screened using tuberculin skin testing, signs and symptoms of TB or leprosy, digital chest X-ray with computer-aided detection and sputum testing (Xpert MTB/RIF Ultra). Those diagnosed with disease are referred to the National TB and Leprosy Programme for management. Participants with TB infection are offered TB preventive treatment and those without TB disease or infection, or leprosy, are offered leprosy prophylaxis. The primary study outcome is the difference in the annual TB case notification rate before and after the intervention; a similar outcome is included for leprosy. The effect on TB transmission will be measured by comparing the estimated annual risk of TB infection in primary school children before and after the intervention, as a co-primary outcome used for power calculations. Comparison of TB and leprosy case notification rates in South Tarawa (the intervention group) and the rest of Kiribati (the control group) before, during and after the intervention is a secondary outcome. ETHICS AND DISSEMINATION: Approval was obtained from the University of Sydney Human Research Ethics Committee (project no. 2021/127) and the Kiribati Ministry of Health and Medical Services (MHMS). Findings will be shared with the MHMS and local communities, published in peer-reviewed journals and presented at international conferences.

Prediction of breast cancer risk among women of the Mariana Islands: the BRISK retrospective case-control study.

OBJECTIVES: To develop a breast cancer risk prediction model for Chamorro and Filipino women of the Mariana Islands and compare its performance to that of the Breast Cancer Risk Assessment Tool (BCRAT). DESIGN: Case-control study. SETTING: Clinics/facilities and other community-based settings on Guam and Saipan (Northern Mariana Islands). PARTICIPANTS: 245 women (87 breast cancer cases and 158 controls) of Chamorro or Filipino ethnicity, age 25-80 years, with no prior history of cancer (other than skin cancer), residing on Guam or Saipan for at least 5 years. PRIMARY AND SECONDARY OUTCOME MEASURES: Breast cancer risk models were constructed using combinations of exposures previously identified to affect breast cancer risk in this population, population breast cancer incidence rates and all-cause mortality rates for Guam. RESULTS: Models using ethnic-specific relative risks performed better than those with relative risks estimated from all women. The model with the best performance among both ethnicities (the Breast Cancer Risk Model (BRISK) model; area under the receiver operating characteristic curve (AUC): 0.64 and 0.67 among Chamorros and Filipinos, respectively) included age at menarche, age at first live birth, number of relatives with breast cancer and waist circumference. The 10-year breast cancer risk predicted by the BRISK model was 1.28% for Chamorros and 0.89% for Filipinos. Performance of the BCRAT was modest among both Chamorros (AUC: 0.60) and Filipinos (AUC: 0.55), possibly due to incomplete information on BCRAT risk factors. CONCLUSIONS: The ability to develop breast cancer risk models for Mariana Islands women is constrained by the small population size and limited availability of health services and data. Nonetheless, we have demonstrated that breast cancer risk prediction models with adequate discriminatory performance can be built for small populations such as in the Mariana Islands. Anthropometry, in particular waist circumference, was important for estimating breast cancer risk in this population.

Modeling thiamine fortification: a case study from Kuria atoll, Republic of Kiribati.

In 2014, there was an outbreak of beriberi on Kuria, a remote atoll in Kiribati, a small Pacific Island nation. A thiamine-poor diet consisting mainly of rice, sugar, and small amounts of fortified flour was likely to blame. We aimed to design a food fortification strategy to improve thiamine intakes in Kuria. We surveyed all 104 households on Kuria with a pregnant woman or a child 0-59 months. Repeat 24-h dietary recalls were collected from 90 men, 17 pregnant, 44 lactating, and 41 other women of reproductive age. The prevalence of inadequate thiamine intakes was >30% in all groups. Dietary modeling predicted that rice or sugar fortified at a rate of 0.3 and 1.4 mg per 100 g, respectively, would reduce the prevalence of inadequate thiamine intakes to <2.5% in all groups. Fortification is challenging because Kiribati imports food from several countries, depending on price and availability. One exception is flour, which is imported from Fiji. Although resulting in less coverage than rice or sugar, fortifying wheat flour with an additional 3.7 mg per 100 g would reduce the prevalence of inadequacy to under 10%. Kiribati is small and has limited resources; thus, a regional approach to thiamine fortification is needed.

Emergence of influenza B/Victoria in the Micronesian US-affiliated Pacific Islands, spring 2019.

Data collected through routine syndromic surveillance for influenza-like illness in the Micronesian United States-affiliated Pacific Islands highlighted out-of-season influenza outbreaks in the spring of 2019. This report describes the data collected through the World Health Organization's Pacific Syndromic Surveillance System for the Commonwealth of the Northern Mariana Islands (CNMI), Guam, the Federated States of Micronesia (FSM) and the Republic of the Marshall Islands (RMI). Compared with historical data, more cases of influenza-like illness were observed in all four islands described here, with the highest number reported in Guam in week 9, CNMI and FSM in week 15, and RMI in week 19. The outbreaks predominantly affected those aged < 20 years, with evidence from CNMI and RMI suggesting higher attack rates among those who were unvaccinated. Cases confirmed by laboratory testing suggested that influenza B was predominant, with 83% (99/120) of subtyped specimens classified as influenza B/Victoria during January-May 2019. These outbreaks occurred after the usual influenza season and were consistent with transmission patterns in Eastern Asia rather than those in Oceania or the United States of America, the areas typically associated with the United States-affiliated Pacific Islands due to their geographical proximity to Oceania and political affiliation with the United States of America. A plausible epidemiological route of introduction may be the high levels of international tourism from Eastern Asian countries recorded during these periods of increased influenza B/Victoria circulation. This report demonstrates the value of year-round surveillance for communicable diseases and underscores the importance of seasonal influenza vaccination, particularly among younger age groups.

Unique pattern of COVID-19 infection in the State of Hawai'i.

This is a brief report on an unusual observation regarding COVID-19 cases. The State of Hawaii is one of the most remote of the Pacific islands and the population is approximately 1.4 million. The racial and ethnic diversity is very high. For example, white Caucasians comprise ∼25%, Asians including Japanese, Chinese, and other Asians account for ∼30%, Hawaiians for 20%, and Pacific Islanders mostly from Micronesia and Samoa comprise ∼4%. We discovered that the COVID-19 rate in the latter group was up to 10 times that in all of the other groups combined and they accounted for almost 30% of cases. Moreover, we are unaware of COVID-19 transmission from Pacific Islanders to islanders with other ethnicities. Thus, there is an epidemic within the epidemic in Hawai'i.

Health and Diet among People Living in an Isolated Area: Case Study of Pingelap Island in Pohnpei State, the Federated States of Micronesia.

Pingelap Island in Pohnpei state is geographically isolated as the nearest island is 70 km away, and such geographical isolation is a challenge for public health due to the limited access to health services. This study aims to reveal the health situation on the island and investigate the influence of geographical isolation on health and diet. For that purpose, the result was compared with those who are living in a community on the main island of Pohnpei state (Mand) with the same ethnic background. Face-to-face interviews were conducted to collect data on demographics, diet, and behavior. Anthropometry and blood pressure measurements were also taken. A total of 98 (Pingelap = 50; Mand = 48) subjects participated in the study. The result showed that females, in particular, had a high prevalence of obesity (80.0% in Pingelap; 75.9% in Mand). However, no significant regional difference was found in both BMI and blood pressure, regardless of gender. Regarding diet, although the geographical location impacted food availability, the consumption of major imported foods did not show a significant regional difference. In conclusion, the geographical isolation did not significantly influence health and diet, but the majority of the study population displayed a high-risk burden of non-communicable diseases.

Prevalence of syphilis, gonorrhoea and chlamydia in women in Fiji, the Federated States of Micronesia, Papua New Guinea and Samoa, 1995-2017: Spectrum-STI model estimates.

OBJECTIVE: To estimate prevalence levels of and time trends for active syphilis, gonorrhoea and chlamydia in women aged 15-49 years in four countries in the Pacific (Fiji, the Federated States of Micronesia [FSM], Papua New Guinea [PNG] and Samoa) to inform surveillance and control strategies for sexually transmitted infections (STIs). METHODS: The Spectrum-STI model was fitted to data from prevalence surveys and screenings of adult female populations collected during 1995-2017 and adjusted for diagnostic test performance and to account for undersampled high-risk populations. For chlamydia and gonorrhoea, data were further adjusted for age and differences between urban and rural areas. RESULTS: Prevalence levels were estimated as a percentage (95% confidence interval). In 2017, active syphilis prevalence was estimated in Fiji at 3.89% (2.82 to 5.06), in FSM at 1.48% (0.93 to 2.16), in PNG at 3.91% (1.67 to 7.24) and in Samoa at 0.16% (0.07 to 0.37). For gonorrhoea, the prevalence in Fiji was 1.63% (0.50 to 3.87); in FSM it was 1.59% (0.49 to 3.58); in PNG it was 11.0% (7.25 to 16.1); and in Samoa it was 1.61% (1.17 to 2.19). The prevalence of chlamydia in Fiji was 24.1% (16.5 to 32.7); in FSM it was 23.9% (18.5 to 30.6); in PNG it was 14.8% (7.39 to 24.7); and in Samoa it was 30.6% (26.8 to 35.0). For each specific disease within each country, the 95% confidence intervals overlapped for 2000 and 2017, although in PNG the 2017 estimates for all three STIs were below the 2000 estimates. These patterns were robust in the sensitivity analyses. DISCUSSION: This study demonstrated a persistently high prevalence of three major bacterial STIs across four countries in WHO's Western Pacific Region during nearly two decades. Further strengthening of strategies to control and prevent STIs is warranted.

Association between the spread of COVID-19 and weather-climatic parameters.

OBJECTIVE: To explore whether the climate has played a role in the COVID-19 outbreak, we compared virus lethality in countries closer to the Equator with others. Lethality in European territories and in territories of some nations with a non-temperate climate was also compared. MATERIALS AND METHODS: Lethality was calculated as the rate of deaths in a determinate moment from the outbreak of the pandemic out of the total of identified positives for COVID-19 in a given area/nation, based on the COVID-John Hopkins University website. Lethality of countries located within the 5th parallels North/South on 6 April and 6 May 2020, was compared with that of all the other countries. Lethality in the European areas of The Netherlands, France and the United Kingdom was also compared to the territories of the same nations in areas with a non-temperate climate. RESULTS: A lower lethality rate of COVID-19 was found in Equatorial countries both on April 6 (OR=0.72 CI 95% 0.66-0.80) and on May 6 (OR=0.48, CI 95% 0.47-0.51), with a strengthening over time of the protective effect. A trend of higher risk in European vs. non-temperate areas was found on April 6, but a clear difference was evident one month later: France (OR=0.13, CI 95% 0.10-0.18), The Netherlands (OR=0.5, CI 95% 0.3-0.9) and the UK (OR=0.2, CI 95% 0.01-0.51). This result does not seem to be totally related to the differences in age distribution of different sites. CONCLUSIONS: The study does not seem to exclude that the lethality of COVID-19 may be climate sensitive. Future studies will have to confirm these clues, due to potential confounding factors, such as pollution, population age, and exposure to malaria.

Oral Cavity Cancer Outcomes in Remote, Betel Nut-Endemic Pacific Islands.

BACKGROUND: Oral cavity carcinomas individually are the fifth-leading cause of overall cancer mortality in the Northern Mariana Islands, which is likely a representative statistic for many other betel-nut-endemic Pacific islands. Factors associated with survival have been minimally evaluated in this region. The purpose of this study is to further characterize oral cavity carcinoma outcomes and associated prognostic factors in the United States commonwealth of the Northern Mariana Islands (CNMI). METHODS: A single-institution retrospective review was undertaken for 81 patients diagnosed with head and neck cancers at the CNMI's only regional hospital complex from 2005 to 2019. A subset of patients diagnosed with oral cavity carcinoma was further evaluated for survival outcomes. Cox proportional hazard regressions were performed to evaluate for variables associated with survival. RESULTS: A majority of patients had cancer of the oral cavity (64/81, 79%). Fifty-five of these patients had sufficient data for review. The average age at the time of diagnosis was 48 and over half were diagnosed with stage IV disease (29/55, 53%). Five-year overall survival (OS) was 49.5% (95% CI, 33.3-63.7%). Factors associated with worse OS were lymph node metastases at presentation (P = .031), higher overall stage (III or IV vs I or II, P = .016), and higher T-stage (III or IV vs I or II, P = .027). Those who used betel nut were diagnosed at a significantly younger age than those who did not (47.2 vs 55.4, P = .001). CONCLUSIONS: The head and neck cancer burden in the CNMI is dominated by betel nut related oral cavity disease that is characterized by delayed presentations in younger patients and decreased OS. Future studies are indicated to improve health literacy as well as to investigate the potential for screening programs.

Lessons from the Field: The Traditional Monarch of Kitti in Pohnpei Addresses the High Rates of Non-Communicable Diseases through Local Policy.

Almost a quarter of Pohnpei's population is overweight or obese, a major factor influencing a 2010 non-communicable diseases (NCD) emergency declaration. The Racial and Ethnic Approaches to Community Health (REACH) project in Pohnpei is implementing a culturally tailored policy, systems, and environmental (PSE) intervention to reduce NCDs through healthy nutrition projects. Through collaboration with traditional leaders and using traditional protocols, REACH succeeded in soliciting formal approval from a Traditional Monarch to serve only healthy beverages during events at all traditional houses in the municipality. The Governor, in turn, also supported this initiative. This project cultivated relationships with traditional and government leaders to implement a culturally appropriate healthy nutrition PSE change intervention.