Protective effect of maritime quarantine in South Pacific jurisdictions, 1918-19 influenza pandemic.

We reviewed mortality data of the 1918-19 influenza pandemic for 11 South Pacific Island jurisdictions. Four of these appear to have successfully delayed or excluded the arrival of pandemic influenza by imposing strict maritime quarantine. They also experienced lower excess death rates than the other jurisdictions that did not apply quarantine measures.

Multicentre survey of incidence and public health impact of leptospirosis in the Western Pacific.

The objectives of the study were to describe the mode of circulation (endemic or epidemic) of human leptospirosis in various Pacific island states and territories by identifying predominant Leptospira serogroups and the most probable routes of human exposure, and to recommend a feasible laboratory strategy for leptospirosis in the Pacific. From September 2003 to December 2005, 263 leptospirosis suspect patients were recruited by public practitioners on 11 Pacific islands, using the WHO case definition. Diagnosis was confirmed using a three-level serology algorithm and a regional laboratory network. Sixty-nine leptospirosis cases were identified from seven islands: Futuna, Raiatea and the Marquesas Islands where outbreaks were apparent, and Vanuatu, Fiji, Palau and Wallis where sporadic cases indicated at least the presence of the disease. Most patients were men aged 17-40 years. The infection appeared to occur during the course of normal daily activities more often than following specific professional exposure. The dominant presumptive serogroups were Icterohaemorrhagiae and Australis, highly suggestive of a rodent reservoir. This study confirms the widespread presence of leptospirosis in the Pacific region. It should help in the implementation of local leptospirosis control plans and highlights the role of on-site laboratory confirmation.

Short communication: Strengthening sub-national communicable disease surveillance in a remote Pacific Island country by adapting a successful African outbreak surveillance model.

Successful communicable disease surveillance depends on effective bidirectional information flow between clinicians at the periphery and communicable disease control units at regional, national and global levels. Resource-poor countries often struggle to establish and maintain the crucial link with the periphery. A simple syndrome-based outbreak surveillance system initially developed and evaluated in Mpumalanga Province, South Africa was adapted for the Pacific island nation of Tuvalu. Eight syndromes were identified for surveillance: acute flaccid paralysis (poliomyelitis), profuse watery diarrhoea (cholera), diarrhoea outbreak, dysentery outbreak, febrile disease with abdominal symptoms and headache (typhoid), febrile disease with generalized non-blistering rash (measles), febrile disease with intense headache and/or neck stiffness with or without haemorrhagic rash (meningococcal meningitis), and outbreaks of other febrile diseases of unknown origin. A user-oriented manual, the Tuvalu Outbreak Manual (http://www.wepi.org/books/tom/), was developed to support introduction of the surveillance system. Nurses working in seven outer island clinics and the hospital outpatient department on the main island rapidly report suspected outbreaks and submit weekly zero-reports to the central communicable disease control unit. An evaluation of the system after 12 months indicated that the Outbreak Manual was regarded as very useful by clinic nurses, and there was early evidence of improved surveillance and response to the disease syndromes under surveillance.

Risk factors for cholera in Pohnpei during an outbreak in 2000: lessons for Pacific countries and territories.

In April 2000, a large outbreak of cholera due to Vibrio cholerae serotype Ogawa biotype El Tor affected the Island of Pohnpei in the Federated States of Micronesia. A Pacific Public Health Surveillance Network team conducted a case control study in the middle of the epidemic. The aims of the study were to identify individual and household level risk factors for cholera, and to evaluate public health interventions aimed at controlling the outbreak. A case was a person admitted to the Pohnpei hospital with acute watery diarrhoea in the months of June and July 2000. We used a pre-tested questionnaire to interview cases about exposures in the five days prior to illness and visited their house to collect water samples, observe hygiene, and assess uptake of health education. 100 mL water samples were filtered and cultured for V. cholerae. We randomly selected neighbouring houses to identify a control that was similar age and sex for each case. Identical observations were made for eligible controls where their household members had not had diarrhoea since the beginning of the epidemic. We stored and analysed data using an Epi Info version 6.04. 53 case control pairs were enrolled into the study. The study identified that storing food outside uncovered, and having a pit latrine as the main toilet were risk factors for cholera infection. There were also several factors that protected against cholera infection, including washing hands after using the toilet and before eating, having a container to store safe water, the presence of soap in kitchen and bathroom, the presence of chlorine bleach and two or more hand washing buckets, a working refrigerator/ice box, and toilet inside or near the house and having a flush toilet. In multivariate analysis, having a working refrigerator/ice box (OR 0.19, 95% CI 0.05-0.70) and Clorox present in the house (OR 0.17, 95% CI 0.04-0.81) were strongly protective against illness. Only 13% (14/106) of case households reported disinfecting household water with chlorine. V. cholerae was isolated from the household water supplies of two controls and one case. During outbreaks of diarrhoeal disease, public health agencies need to aggressively advise affected communities to: disinfect drinking water with clorox bleach, store water in narrow-necked containers, and prepare and store food safely. Health authorities should use multiple strategies inform people about preventive hygiene measures, and implement vaccine campaigns early in outbreaks of cholera. Improvements in sanitation and hygiene are needed to prevent further cholera epidemics in the Pacific.

Dengue in the Pacific--an update of the current situation.

Dengue continues to be a threat to Pacific Island countries and territories (PICTs). The last DEN-1 epidemic reached 16 PICTs and in some of them it affected as much as 20 per cent of the population, aside from the massive impact on their fragile economies. Dengue is mostly introduced into PICTs from global travel, and many experts believe that it has a 3-4 year cyclical pattern of occurrence. All four virus serotypes (DEN-1, 2, 3 and 4) have caused epidemics, but those caused by DEN-1 and 2 have been somewhat larger. In light of this, dengue rightly remains a priority for the Pacific Public Health Surveillance Network (PPHSN). The paper updates the situation regarding dengue outbreaks in PICTs over the last four decades, describes the pattern of presentations in the recent past, and provides an update on the potential risk to PICTs for the near future. It follows on from an earlier dengue update written in 1998. The utility of PPHSN services is also demonstrated in the paper: PacNet for alerts and communication about dengue outbreaks (raising awareness and preparedness levels in the region) and LabNet for investigations relating to dengue. Creative interventions towards dengue control and prevention are being tried in PICTs and early assessment and evaluations of their effectiveness in the field are being examined.

Implementing the new International Health Regulations in the Pacific--challenges and opportunities.

The newly revised International Health Regulations, i.e. IHR (2005), adopted by the World Health Assembly in May 2005, are the legally binding international instruments for preventing and controlling international spread of disease while avoiding unnecessary interference with international traffic and trade. IHR (2005), which will enter into force in June 2007, set out new obligations for detection, assessment and notification of and response to public health events of international concern. In particular, under the IHR (2005), each Member State is required to notify WHO directly of any event that may consititue a public health emergency of international concern. Although the implementation of the new IHR to contribute to regional and global health security will be very challenging in the Pacific, they provide new opportunities for the Pacific Island Countries and areas (PICs) to build, strengthen and maintain their core capacities for surveillance and response. This article describes the major changes in the new Regulations and discusses the opportunity of using existing mechanisms for the implementation of IHR (2005). In the PICs, while strengthening the capacity of national public health surveillance and response systems is essential and the key to the effective implementation of the new Regulations, the Pacific Public Health Surveillance Network (PPHSN) can also be utilized to facilitate the IHR implementation, including disseminating updated information related to IHR such as WHO guidelines and capacity building, whenever possible.