Effects of inappropriate cause-of-death certification on mortality from cardiovascular disease and diabetes mellitus in Tonga.

BACKGROUND: Cardiovascular disease (CVD) and diabetes mellitus are major health issues in Tonga and other Pacific countries, although mortality levels and trends are unclear. We assess the impacts of cause-of-death certification on coding of CVD and diabetes as underlying causes of death (UCoD). METHODS: Tongan records containing cause-of-death data (2001-2018), including medical certificates of cause-of-death (MCCD), had UCoD assigned according to International Classification of Diseases 10th revision (ICD-10) coding rules. Deaths without recorded cause were included to ascertain total mortality. Diabetes and hypertension causes were reallocated from Part 1 of the MCCD (direct cause) to Part 2 (contributory cause) if potentially fatal complications were not recorded, and an alternative UCoD was assigned. Proportional mortality by cause based on the alternative UCoD were applied to total deaths then mortality rates calculated by age and sex using census/intercensal population estimates. CVD and diabetes mortality rates for unaltered and alternative UCoD were compared using Poisson regression. RESULTS: Over 2001-18, in ages 35-59 years, alternative CVD mortality was higher than unaltered CVD mortality in men (p = 0.043) and women (p = 0.15); for 2010-18, alternative versus unaltered measures in men were 3.3/103 (95%CI: 3.0-3.7/103) versus 2.9/103 (95%CI: 2.6-3.2/103), and in women were 1.1/103 (95%CI: 0.9-1.3/103) versus 0.9/103 (95%CI: 0.8-1.1/103). Conversely, alternative diabetes mortality rates were significantly lower than the unaltered rates over 2001-18 in men (p < 0.0001) and women (p = 0.013); for 2010-18, these measures in men were 1.3/103 (95%CI: 1.1-1.5/103) versus 1.9/103 (95%CI: 1.6-2.2/103), and in women were 1.4/103 (95%CI: 1.2-1.7/103) versus 1.7/103 (95%CI: 1.5-2.0/103). Diabetes mortality rates increased significantly over 2001-18 in men (unaltered: p < 0.0001; alternative: p = 0.0007) and increased overall in women (unaltered: p = 0.0015; alternative: p = 0.014). CONCLUSIONS: Diabetes reporting in Part 1 of the MCCD, without potentially fatal diabetes complications, has led to over-estimation of diabetes, and under-estimation of CVD, as UCoD in Tonga. This indicates the importance of controlling various modifiable risks for atherosclerotic CVD (including stroke) including hypertension, tobacco use, and saturated fat intake, besides obesity and diabetes. Accurate certification of diabetes as a direct cause of death (Part 1) or contributory factor (Part 2) is needed to ensure that valid UCoD are assigned. Examination of multiple cause-of-death data can improve understanding of the underlying causes of premature mortality to better inform health planning.

Comparing and contrasting Tongan youth and service users' interpretations of mental distress.

BACKGROUND: In Aotearoa New Zealand (NZ), Pacific people have a higher prevalence of mental illness compared with the general population. Tongan people have high rates of mental illness and tend to not use mental health services. The risk for mental illnesses also differs between those born in Tonga and those born in NZ. AIM: This study presented the views of New Zealand-dwelling Tongan youth and mental health service users regarding the meaning of mental distress. METHODS: A Tongan cultural framework "talanoa" was used to inform the approach to the research. The youth talanoa group had seven participants and the service users talanoa group had twelve participants. Braun and Clarke's thematic analysis was used to analyse the data. RESULTS: Tongan youth and service users constructed mental distress from biopsychosocial perspectives and challenged traditional Tongan perspectives around being possessed by spirits, cursed and disruptions to social and spiritual relationships. CONCLUSIONS: The youth and service users construct mental distress from a biopsychosocial angle and there is a need for further information about Tongan perspectives of mental distress. This suggests that a biopsychosocial perspective is needed to ensure engagement by Tongan youth and service users in promoting mental health and alleviating distress.

A test of the resource security and the body mass index reference point hypotheses of body dissatisfaction amongst adolescents in eight countries.

OBJECTIVE: This study aimed to identify cultural-level variables that may influence the extent to which adolescents from different cultural groups are dissatisfied with their bodies. DESIGN: A sample of 1730 male and 2000 female adolescents from Australia, Fiji, Malaysia, Tonga, Tongans in New Zealand, China, Chile, and Greece completed measures of body satisfaction, and the sociocultural influences on body image and body change questionnaire, and self-reported height and weight. Country gross domestic product and national obesity were recorded using global databases. RESULTS: Prevalence of obesity/overweight and cultural endorsement of appearance standards explained variance in individual-level body dissatisfaction (BD) scores, even after controlling for the influence of individual differences in body mass index and internalization of appearance standards. CONCLUSIONS: Cultural-level variables may account for the development of adolescent BD.

Va'a fakalelei 'atamai: restoring the mind in the Kingdom of Tonga.

OBJECTIVE: We aim to report on the practice of psychiatry in the Kingdom of Tonga. METHOD: We provide a description of the findings from a visit to Vaiola Hospital and data provided by the chief psychiatrist of Tonga. RESULTS: The practice of psychiatry in Tonga reflects the difficulties of providing health care in a middle-income micro state. Interesting features include the use of kava as a calmative for some acutely disturbed and anxious patients, the high proportion of patients receiving treatment with fluphenazine decanoate and the possibility that the observed increase in psychosis among Tongan migrants to Australia is at least partly due to a high prevalence of psychosis in Tonga itself. CONCLUSIONS: A prevalence of psychosis study would need to be undertaken to confirm the report of a higher rate of psychosis in Tonga compared with that in Australia.

Operational research to inform post-validation surveillance of lymphatic filariasis in Tonga study protocol: History of lymphatic filariasis elimination, rational, objectives, and design.

BACKGROUND: Lymphatic filariasis (LF), a mosquito-borne helminth infection, is an important cause of chronic disability globally. The World Health Organization has validated eight Pacific Island countries as having eliminated lymphatic filariasis (LF) as a public health problem, but there are limited data to support an evidence-based approach to post-validation surveillance (PVS). Tonga was validated as having eliminated LF in 2017 but no surveillance has been conducted since 2015. This paper describes a protocol for an operational research project investigating different PVS methods in Tonga to provide an evidence base for national and regional PVS strategies. METHODS: Programmatic baseline surveys and Transmission Assessment Surveys conducted between 2000-2015 were reviewed to identify historically 'high-risk' and 'low-risk' schools and communities. 'High-risk' were those with LF antigen (Ag)-positive individuals recorded in more than one survey, whilst 'low-risk' were those with no recorded Ag-positives. The outcome measure for ongoing LF transmission will be Ag-positivity, diagnosed using Alere™ Filariasis Test Strips. A targeted study will be conducted in May-July 2024 including: (i) high and low-risk schools and communities, (ii) boarding schools, and (iii) patients attending a chronic-disease clinic. We estimate a total sample size of 2,010 participants. CONCLUSIONS: Our methodology for targeted surveillance of suspected 'high-risk' populations using historical survey data can be adopted by countries when designing their PVS strategies. The results of this study will allow us to understand the current status of LF in Tonga and will be used to develop the next phase of activities.

Type 2 Diabetes Prevalence, Control and Management within Fiji,Kiribati, Samoa, the Solomon Islands, Tonga, and Vanuatu: A ScopingReview with a Systematic Approach.

BACKGROUND: Type 2 diabetes (T2D) causes significant morbidity and is disproportionately prevalent in Pacific Island Countries (PICs). The socio-political demographics of PICs are rapidly changing, and health services must adapt to match the needs of their population. OBJECTIVES: The objective of this study was to review the literature published within the last 15 years relating to T2D prevalence, control, and management, with a specific focus on targetable areas for future funding and research projects. METHODS: This review was conducted using the PRISMA guidelines. Inclusion criteria were: discussion on T2D in the six PICs. Results were limited to those published between 1st January, 2006, and 27th July, 2023. RESULTS: A total of 6,640 publications were retrieved, and 110 met the inclusion criteria. Nineteen additional studies were identified through hand-searching. T2D prevalence differed between countries but was predicted to increase in the coming decades, with projections of up to 31.2% by 2030 in Tonga. Factors associated with T2D varied between countries, including Indian-Fijian ethnicity in Fiji and tuberculosis in Kiribati. Control was generally poor, with high rates of undiagnosed diabetes and microvascular complications. Epidemiological data was limited in some cases, as was information describing the structure and function of diabetes services. CONCLUSION: The prevalence, control, and management of T2D varied between Fiji, Kiribati, Samoa, the Solomon Islands, Tonga, and Vanuatu. Significant gaps remain in the data describing these domains; however, there are clearly targetable areas for future research and diabetes management programs.

A functional SNP upstream of the beta-2 adrenergic receptor gene (ADRB2) is associated with obesity in Oceanic populations.

OBJECTIVE: Obesity is a growing health concern in the Oceanic populations. To investigate the genetic factors associated with adult obesity in the Oceanic populations, the association of single nucleotide polymorphisms (SNPs) of the beta-2 adrenergic receptor (ADRB2) gene with obesity was examined in 694 adults living in Tonga and Solomon Islands. RESULTS: A screening for variation in 16 Oceanic subjects detected 17 SNPs in the entire region of ADRB2, of which nine SNPs including two non-synonymous ones, rs1042713 (Arg16Gly) and rs1042714 (Gln27Glu), were further genotyped for all subjects. The rs34623097-A allele, at a SNP located upstream of ADRB2, showed the strongest association with risk for obesity in a logistic regression analysis adjusted for age, sex, and population (P=5.6 × 10(-4), odds ratio [OR]=2.5, 95% confidence interval [CI]=1.5-4.2). The 27Glu was also significantly associated with obesity in the single-point association analysis (P=0.013, OR=2.0, 95%CI=1.2-3.4); however, this association was no longer significant after adjustment for rs34623097 since these SNPs were in linkage disequilibrium with each other. A copy of the obesity-risk allele, rs34623097-A, led to a 1.6 kg/m(2) increase in body mass index (BMI; defined as weight in kilograms divided by height in meters squared) (P=0.0019). A luciferase reporter assay indicated that rs34623097-A reduced the transcriptional activity of the luciferase reporter gene by approximately 10% compared with rs34623097-G. An electrophoretic mobility shift assay demonstrated that rs34623097 modulated the binding affinity with nuclear factors. An evolutionary analysis implies that a G>A mutation at rs34623097 occurred in the Neandertal genome and then the rs34623097-A allele flowed into the ancestors of present-day humans. CONCLUSION: The present results suggest that rs34623097-A, which would lead to lower expression of ADRB2, contributes to the onset of obesity in the Oceanic populations.

Sizing the association between lifestyle behaviours and fatness in a large, heterogeneous sample of youth of multiple ethnicities from 4 countries.

BACKGROUND: The magnitude of the relationship between lifestyle risk factors for obesity and adiposity is not clear. The aim of this study was to clarify this in order to determine the level of importance of lifestyle factors in obesity aetiology. METHODS: A cross-sectional analysis was carried out on data on youth who were not trying to change weight (n = 5714), aged 12 to 22 years and from 8 ethnic groups living in New Zealand, Australia, Fiji and Tonga. Demographic and lifestyle data were measured by questionnaires. Fatness was measured by body mass index (BMI), BMI z-score and bioimpedance analysis, which was used to estimate percent body fat and total fat mass (TFM). Associations between lifestyle and body composition variables were examined using linear regression and forest plots. RESULTS: TV watching was positively related to fatness in a dose-dependent manner. Strong, dose-dependent associations were observed between fatness and soft drink consumption (positive relationship), breakfast consumption (inverse relationship) and after-school physical activity (inverse relationship). Breakfast consumption-fatness associations varied in size across ethnic groups. Lifestyle risk factors for obesity were associated with percentage differences in body composition variables that were greatest for TFM and smallest for BMI. CONCLUSIONS: Lifestyle factors were most strongly related to TFM, which suggests that studies that use BMI alone to quantify fatness underestimate the full effect of lifestyle on adiposity. This study clarifies the size of lifestyle-fatness relationships observed in previous studies.

Natural experiment evidence on the effect of migration on blood pressure and hypertension.

Over 200 million people worldwide live outside their country of birth and typically experience large gains in material well-being by moving to where wages are higher. But, the effect of this migration on other dimensions of well-being such as health are less clear and existing evidence is ambiguous because of potential for self-selection bias. In this paper, we use a natural experiment, comparing successful and unsuccessful applicants to a migration lottery to experimentally estimate the impact of migration on measured blood pressure and hypertension. Hypertension is a leading global health problem, as well as being an important health measure that responds quickly to migration. We use various econometric estimators to form bounds on the treatment effects because there appears to be selective non-compliance in the natural experiment. Even with these bounds, the results suggest significant and persistent increases in blood pressure and hypertension, which are likely to have implications for future health budgets given recent increases in developing to developed country migration.

Associations between HLA class I alleles and escape mutations in the hepatitis B virus core gene in New Zealand-resident Tongans.

The full repertoire of hepatitis B virus (HBV) peptides that bind to the common HLA class I molecules found in areas with a high prevalence of chronic HBV infection has not been determined. This information may be useful for designing immunotherapies for chronic hepatitis B. We identified amino acid residues under positive selection pressure in the HBV core gene by phylogenetic analysis of cloned DNA sequences obtained from HBV DNA extracted from the sera of Tongan subjects with inactive, HBeAg-negative chronic HBV infections. The repertoires of positively selected sites in groups of subjects who were homozygous for either HLA-B*4001 (n = 10) or HLA-B*5602 (n = 7) were compared. We identified 13 amino acid sites under positive selection pressure. A significant association between an HLA class I allele and the presence of nonsynonymous mutations was found at five of these sites. HLA-B*4001 was associated with mutations at E77 (P = 0.05) and E113 (P = 0.002), and HLA-B*5602 was associated with mutations at S21 (P = 0.02). In addition, amino acid mutations at V13 (P = 0.03) and E14 (P = 0.01) were more common in the seven subjects with an HLA-A*02 allele. In summary, we have developed an assay that can identify associations between HLA class I alleles and HBV core gene amino acids that mutate in response to selection pressure. This is consistent with published evidence that CD8(+) T cells have a role in suppressing viral replication in inactive, HBeAg-negative chronic HBV infection. This assay may be useful for identifying the clinically significant HBV peptides that bind to common HLA class I molecules.

Testing the thrifty gene hypothesis: the Gly482Ser variant in PPARGC1A is associated with BMI in Tongans.

BACKGROUND: the thrifty gene hypothesis posits that, in populations that experienced periods of feast and famine, natural selection favoured individuals carrying thrifty alleles that promote the storage of fat and energy. Polynesians likely experienced long periods of cold stress and starvation during their settlement of the Pacific and today have high rates of obesity and type 2 diabetes (T2DM), possibly due to past positive selection for thrifty alleles. Alternatively, T2DM risk alleles may simply have drifted to high frequency in Polynesians. To identify thrifty alleles in Polynesians, we previously examined evidence of positive selection on T2DM-associated SNPs and identified a T2DM risk allele at unusually high frequency in Polynesians. We suggested that the risk allele of the Gly482Ser variant in the PPARGC1A gene was driven to high frequency in Polynesians by positive selection and therefore possibly represented a thrifty allele in the Pacific. METHODS: here we examine whether PPARGC1A is a thrifty gene in Pacific populations by testing for an association between Gly482Ser genotypes and BMI in two Pacific populations (Maori and Tongans) and by evaluating the frequency of the risk allele of the Gly482Ser variant in a sample of worldwide populations. RESULTS: we find that the Gly482Ser variant is associated with BMI in Tongans but not in Maori. In a sample of 58 populations worldwide, we also show that the 482Ser risk allele reaches its highest frequency in the Pacific. CONCLUSION: the association between Gly482Ser genotypes and BMI in Tongans together with the worldwide frequency distribution of the Gly482Ser risk allele suggests that PPARGC1A remains a candidate thrifty gene in Pacific populations.

Energy and nutrient intake of Tongan adults estimated by 24-hour recall: the importance of local food items.

Tongan adults show one of the highest prevalences of obesity in the world. The present study aims to estimate Tongans' energy and nutrient intakes and food sources using a 24-hour recall survey for 14 days targeting 15 men and 19 women. The mean (SD) daily energy intake was 12.2 (2.3) MJ for men and 10.6 (2.2) MJ for women. Imported foods accounted for about half of their energy and macronutrient intakes, but for much less of their micronutrients. Some local food items, specifically pork, kava, and sea hare, contributed significantly to their vitamin, Fe, and Ca intakes, respectively. These findings suggest that heavy reliance on imported foods can lead not only to a high prevalence of obesity, but also to micronutrient deficiencies.

Evaluation of vision screening of 5-15-year-old children in three Tongan schools: comparison of The Auckland Optotypes and Lea symbols.

BACKGROUND: Comprehensive vision screening programmes for children are an important part of public health strategy, but do not exist in many countries, including Tonga. This project set out to assess: (1) the functional vision of children attending primary schools in Tonga and (2) how a new recognition acuity test (The Auckland Optotypes displayed on a tablet computer) compares to use of a standardised eye chart in this setting. METHODS: Children from three Tongan primary schools were invited to participate. Acuity testing was conducted using a standardised recognition acuity chart (Lea symbols) and the tablet test displaying two formats of The Auckland Optotypes. Measures of ocular alignment, stereo acuity and non-cycloplegic photorefraction were also taken. RESULTS: Parents of 249 children consented to participate. One child was untestable. Only 2.8 per cent of testable children achieved visual acuity worse than 0.3 logMAR in the weaker eye. Results from the Spot Photoscreener suggested that no children had myopia or hyperopia, but that some children had astigmatism. The tablet test was practical in a community setting, and showed ±0.2 logMAR limits of agreement with the Lea symbols chart. CONCLUSION: The sample of children in Tongan primary schools had good functional vision. A modified version of the tablet acuity test is a promising option for vision screening in this context.

Lessons from the Pacific programme to eliminate lymphatic filariasis: a case study of 5 countries.

BACKGROUND: Lymphatic Filariasis (LF) is an important Neglected Tropical Disease, being a major cause of disability worldwide. The Global Programme to Eliminate Lymphatic Filariasis aims to eliminate LF as a public health problem by the year 2020, primarily through repeated Mass Drug Administration (MDA). The Pacific region programme commenced in 1999. By June 2007, five of the eleven countries classified as endemic had completed five MDA campaigns and post-MDA prevalence surveys to assess their progress. We review available programme data and discuss their implications for other LF elimination programs in developing countries. METHODS: Reported MDA coverage and results from initial surveys and post-MDA surveys of LF using the immunochromatographic test (ICT) from these five Pacific Island countries (Tonga, Niue, Vanuatu, Samoa and Cook Islands) were analysed to provide an understanding of their quality and programme progress towards LF elimination. Denominator data reported by each country programme for 2001 was compared to official sources to assess the accuracy of MDA coverage data. RESULTS: Initial survey results from these five countries revealed an ICT prevalence of between 2.7 and 8.6 percent in individuals tested prior to commencement of the programme. Country MDA coverage results varied depending on the source of denominator data. Of the five countries in this case study, three countries (Tonga, Niue and Vanuatu) reached the target prevalence of <1% antigenaemia following five rounds of MDA. However, endpoint data could not be reliably compared to baseline data as survey methodology varied. CONCLUSION: Accurate and representative baseline and post-campaign prevalence data is crucial for determining program effectiveness and the factors contributing to effectiveness. This is emphasised by the findings of this case study. While three of the five Pacific countries reported achieving the target prevalence of <1% antigenaemia, limitations in the data preclude identification of key determinants of this achievement.

Cancer disparities in indigenous Polynesian populations: Maori, Native Hawaiians, and Pacific people.

Polynesia consists of several islands that are scattered across a vast triangle in the Pacific, and include New Zealand, Hawaii, and the Pacific islands. There are reported differences in the types of cancer and epidemiologies seen among communities in these islands, the reasons for which are diverse and complex. In this Review, we describe patterns of cancer incidence, mortality, and survival in indigenous populations compared with populations of European origin in Polynesia, and highlight the limited available data for Pacific populations. Additionally, we document the current knowledge of the underlying biology of cancers in these populations, and report risk factors that differ between ethnicities, including smoking, viral infections, and obesity. Disparities in measures of health are highlighted, as are evident differences in knowledge of tumour biology and cancer management between majority and minority populations.

Me'akai in Tonga: Exploring the Nature and Context of the Food Tongan Children Eat in Ha'apai Using Wearable Cameras.

Unhealthy food consumption is a key driver of the global pandemic in non-communicable diseases (NCDs). The Government of Tonga has prioritised NCD prevention due to the very high rates of NCDs in the Kingdom. This research examines the nature and context of the me'akai (food) consumed by Tongan children in Ha'apai using wearable cameras. Thirty-six randomly selected 11-year-old children used wearable cameras to record their lives for three days, as part of the wider Kids'Cam Tonga project. Images were analysed to assess the participants' food consumption according to a new data analysis protocol for Tonga. Core foods were defined as including breads and cereals, fresh fruit, vegetables, meat and alternatives, and staple vegetables. Non-core food types included confectionery, unhealthy snack foods, edible ices, and processed meat. Tongan researchers led the research in partnership with the Government of Tonga. Overall, children were observed to have consumed a mean of 4.5 (95% CI 3.3, 6.7) non-core and 2.3 (95% CI 1.8, 2.9) core foods per 10 h day, excluding mixed meals. Unhealthy snack foods, confectionary, and cookies, cakes, and desserts were the most commonly consumed non-core foods, and fresh fruit was the most frequently consumed core food. Snacking was the most frequent eating episode observed, with children snacking on non-core foods four times a day (95% confidence interval (CI) 2.5 to 6.2) compared to 1.8 (95% CI 1.3 to 2.6) core food snacks per day. Most commonly, children were observed eating at home, at school, and on the road while out walking. The most common sources of food were the home, other children, and the supermarket. On average, children consumed one purchased product per day, almost all (90%) of which were non-core. Children were also observed eating an average of just less than one mixed meal per day. Less than half (45.2%) of all mixed meals observed were traditional foods. This research illustrates the presence, and likely dominance, of energy-dense nutrient-poor (EDNP) foods in the diet of these Tongan children. It highlights a transition from a traditional diet and suggests that these children live in an obesogenic environment, one that promotes obesity as a normal response to an abnormal environment. The findings support efforts by the Government of Tonga for the implementation of a healthy School Food Policy, junk food taxes, and initiatives to ban the importation of EDNP foods. This study has relevance for other Pacific Island nations and all nations concerned with addressing obesity and other diet-related NCDs.

Intentional injury reported by young people in the Federated States of Micronesia, Kingdom of Tonga and Vanuatu.

BACKGROUND: Intentional injury presents a threat to the physical and psychological well being of young people, especially in developing countries, which carry the greatest part of the global injury burden. While the importance of this problem is recognized, there are limited population data in low and middle income countries that can guide public health action. The present study investigates the prevalence and distribution of intentional injury among young people in three Pacific Island societies, and examines behavioural and psychosocial factors related to risk of intentional injury. METHODS: Population surveys were conducted with students aged 11-17 years in Pohnpei State in the Federated States of Micronesia (n = 1495), the Kingdom of Tonga (n = 2808) and Vanuatu (n = 4474). Surveys measured self-reported injury and intentional injury, sources of intentional injury, and the range of behavioural, psychological, educational and social variables that may be related to injury risk. RESULTS: Among boys and girls aged 14-17 years the respective period prevalence of intentional injury was 62% and 56% in Pohnpei, 58% and 41% in Tonga, and 33% and 24% in Vanuatu. The prevalence of intentional injury declined with age in Tonga and Vanuatu, but there was little evidence of an age-trend in Pohnpei. Across the three societies, the major sources of intentional injury among boys were 'other persons' followed by boyfriends/girlfriends and fathers. Mothers, boyfriends/girlfriends and other persons were primary sources of injury among girls. An intentional injury was reported more often by those who had been bullied (OR 1.40-1.66, P < 0.05), by regular smokers in Tonga and Vanuatu (OR 1.52-2.21, P < 0.05), and illicit drug users in Pohnpei and Vanuatu (OR 1.87-1.92, P < 0.05). CONCLUSION: Intentional injury was reported extensively in these three populations. Interventions directed towards the school environment and which take into account the role of bullying and drug use need to be considered.

Comparison of tobacco, alcohol and illegal drug usage among school students in three Pacific Island societies.

BACKGROUND: Many Pacific Island countries are in social and epidemiological transition, but there are little population data about drug and alcohol usage among adolescents in this region. METHODS: Random samples of school students aged 11-17 years completed surveys in three populations: Pohnpei State in the Federated States of Micronesia (n=1495), Tonga (n=2808) and Vanuatu (n=4474). RESULTS: Among 15-year-olds, boys in Tonga reported the highest prevalence of weekly smoking (29%), followed by boys in Pohnpei (17%). Kava use at a potentially harmful level (i.e. daily) was low in all countries. Drunkenness on two or more occasions was much more common among 15-year-old boys in Pohnpei (51%) than same-age youth in the other countries. Marijuana use was most often reported by boys (20%) and girls (20%) in Pohnpei, while solvents had been used most often by boys in Pohnpei (15%), and methylated spirits by boys in Tonga (20%). In all countries bullying of other students was independently related to regular smoking, while bullying behaviour and strong relationships with peers and others outside of the family were related to past drunkenness and use of illegal drugs in Tonga and Vanuatu. CONCLUSIONS: Overall, levels of adolescent substance use were consistently higher in Tonga and Pohnpei than in Vanuatu. These unique data provide a basis for setting priorities and evaluating action to address the health risks posed by substance use in these Pacific Island societies.

Invasive Pneumococcal Disease in Children in Tonga.

In Tonga, pneumococcal conjugate vaccine is not a scheduled immunization. We identified all children in Tonga with invasive pneumococcal disease from 2010 to 2013. The average annual invasive pneumococcal disease incidence rate was 113/100,000 (<2 years), 50/100,000 (<5 years) and 25/100,000 (<15 years). The case fatality rate (<5 years) was 25%. The incidence rate and high case fatality rate indicate the need for pneumococcal conjugate vaccine.

Evaluation of the child oral health promotion 'MaliMali' Programme based on schools in the Kingdom of Tonga.

INTRODUCTION: The South Pacific Medical Team (SPMT) has supported oral health care for Tongan juveniles since 1998. This voluntary activity, named the MaliMali ('smile' in Tongan) Programme, is evaluated in detail in this paper. METHODS: This evaluation was guided by the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. The objectives were to explore: (i) whether the programme was accessible to Tongan schoolchildren (Reach); (ii) the impact of the programme on decayed, missing and filled teeth (DMFT) scores and toothbrushing habits (Effectiveness); (iii) factors that affected the adoption of the programme (Adoption); (iv) whether implementation was consistent with the programme model (Implementation); and (v) the long-term sustainability of the programme (Maintenance). RESULTS: The MaliMali Programme has grown into an international project, has spread countrywide as a uniform health promotion and is reaching children in need. Following implementation of this programme, the oral health of Tongan juveniles has improved, with a decrease in the mean DMFT index and an increase in toothbrushing. To provide training that will allow Tongans to assume responsibility for the MaliMali Programme in the future, dental health education literature was prepared and workshops on oral hygiene and the MaliMali Programme were held frequently. At present, the programme is predominantly managed by Tongan staff, rather than by Japanese staff. CONCLUSIONS: This evaluation found the MaliMali Programme to be feasible and acceptable to children and schools in the Kingdom of Tonga. The programme promotes oral health and provides accessible and improved oral health care in the school setting, consistent with the oral health-promoting school framework.