Gap analysis of diabetes-related foot disease management systems in Pacific Islands Countries and Territories.

BACKGROUND: Pacific Island Countries and Territories (PICTs) are known to have high prevalence of Diabetes Mellitus and high incidence of diabetes-related foot disease. Diabetes-related foot disease can lead to lower limb amputation and is associated with poor outcomes, with increased morbidity and mortality. The purpose of this study was to gain a better understanding of diabetes-related foot disease management in selected countries in PICTs and to identify potential barriers in management of diabetes-related foot disease management in the region. METHODS: A cross-sectional survey was sent to eleven hospitals across six selected PICTs. The survey instrument was designed to provide an overview of diabetes-related foot disease (number of admissions, and number of lower limb amputations over 12 months) and to identify clinical services available within each institution. Two open-ended questions (free text responses) were included in the instrument to explore initiatives that have helped to improve management and treatment of diabetes-related foot diseases, as well as obstacles that clinicians have encountered in management of diabetes-related foot disease. The survey was conducted over 6 weeks. RESULTS: Seven hospitals across four countries provided responses. Number of admissions and amputations related to diabetes-related foot disease were only reported as an estimate by clinicians. Diabetes-related foot disease was managed primarily by general medicine physician, general surgeon and/or orthopaedic surgeon in the hospitals surveyed, as there were no subspecialty services in the region. Only one hospital had access to outpatient podiatry. Common themes identified around barriers faced in management of diabetes-related foot disease by clinicians were broadly centred around resource availability, awareness and education, and professional development. CONCLUSION: Despite the high prevalence of diabetes-related foot disease within PICTs, there appears to be a lack of functional multi-disciplinary foot services (MDFs). To improve the outcomes for diabetes-related foot disease patients in the region, there is a need to establish functional MDFs and engage international stakeholders to provide ongoing supports in the form of education, mentoring, as well as physical resources.

Clinical manifestations of dengue, Zika and chikungunya in the Pacific Islands: A systematic review and meta-analysis.

Dengue, Zika and chikungunya outbreaks pose a significant public health risk to Pacific Island communities. Differential diagnosis is challenging due to overlapping clinical features and limited availability of laboratory diagnostic facilities. There is also insufficient information regarding the complications of these arboviruses, particularly for Zika and chikungunya. We conducted a systematic review and meta-analysis to calculate pooled prevalence estimates with 95% confidence intervals (CI) for the clinical manifestations of dengue, Zika and chikungunya in the Pacific Islands. Based on pooled prevalence estimates, clinical features that may help to differentiate between the arboviruses include headache, haemorrhage and hepatomegaly in dengue; rash, conjunctivitis and peripheral oedema in Zika; and the combination of fever and arthralgia in chikungunya infections. We estimated that the hospitalisation and mortality rates in dengue were 9.90% (95% CI 7.67-12.37) and 0.23% (95% CI 0.16-0.31), respectively. Severe forms of dengue occurred in 1.92% (95% CI 0.72-3.63) of reported cases and 23.23% (95% CI 13.58-34.53) of hospitalised patients. Complications associated with Zika virus included Guillain-Barré syndrome (GBS), estimated to occur in 14.08 (95% CI 11.71-16.66) per 10,000 reported cases, and congenital brain malformations such as microcephaly, particularly with first trimester maternal infection. For chikungunya, the hospitalisation rate was 2.57% (95% CI 1.30-4.25) and the risk of GBS was estimated at 1.70 (95% CI 1.06-2.48) per 10,000 reported cases. Whilst ongoing research is required, this systematic review enhances existing knowledge on the clinical manifestations of dengue, Zika and chikungunya infections and will assist Pacific Island clinicians during future arbovirus outbreaks.

Research on the changes and predictions of the burden of type 2 diabetes mellitus in Pacific Island countries from 1990 to 2019.

AIMS: To assess the burden of type 2 diabetes in Pacific Island countries and predict future trends. METHODS: We analyzed and processed data using R and Excel software, performed Joinpoint 4.7.0 software analysis to investigate changing trends in disease burden, and used an autoregressive integrated moving average model to forecast future trends. RESULTS: Our study showed that from 1990 to 2019, the burden of type 2 diabetes in Pacific Island countries continues to increase, with the standardized incidence rate showing the most significant growth. Moreover, there were significant differences in the burden of type 2 diabetes between regions. In 2019, American Samoa had the highest standardized incidence rate, while Fiji had the highest standardized death rate and disability-adjusted life year rate. The standardized incidence rate peaked at ages 65-69 years, while the standardized death rate and disability-adjusted life year rate peaked at ages 95 years and 70-74 years respectively. Type 2 diabetes burden was higher among males than females. Based on our forecasting, from 2020 to 2030, the standardized incidence rate is expected to continue to rise, while the standardized death rate and disability-adjusted life year rate will slowly decline. CONCLUSIONS: Our study highlights that the burden of type 2 diabetes in Pacific Island countries has been increasing from 1990 to 2019. Therefore, it is imperative to strengthen disease prevention and control measures in the region.

Analysis of the burden and trends of communicable diseases in Pacific Island countries from 1990 to 2019.

BACKGROUND: Communicable diseases contribute substantially to morbidity and death rates worldwide, particularly in low-and middle-income countries. Pacific Island countries face unique challenges in addressing these diseases due to their remote locations and limited resources. Understanding the burden and trends of these diseases in this region is crucial for developing effective public health interventions. OBJECTIVE: This study aimed to analyze the burden and trends of communicable diseases in Pacific Island countries from 1990 to 2019. METHODS: We utilized data from the 2019 Global Burden of Disease (GBD) study to analyze indicators including incidence, death, and disability-adjusted life years (DALYs). Excel 2016, R 4.2.1, and GraphPad Prism 9 were used to analyze and visualize the data. Joinpoint regression models were used for trend analysis, and the average annual percent change (AAPC) was calculated. RESULTS: From 1990 to 2019, the standardized incidence rate of communicable diseases in Pacific Island countries showed an upward trend (AAPC = 0.198%, 95% CI = 0.0174 ~ 0.221), while the standardized death rate (AAPC = -1.098%, 95% CI = -1.34 ~ 0.86) and standardized DALY rate (AAPC = -1.008%, 95% CI = -1.187 ~ -0.828) showed downward trends. In 2019, the standardized incidence, death, and DALY rates of communicable diseases were higher among males than among females, but the standardized death and DALY rates among males decreased faster than those among females from 1990 to 2019. There were significant differences in the disease burden among different Pacific Island countries. The Solomon Islands had the highest standardized death rate (363.73/100,000), and Guam had the lowest (50.42/100,000). Papua New Guinea had the highest standardized DALY rate (16,041.14/100,000), and the Cook Islands had the lowest (2,740.13/100,000). In 2019, the main attributable risk factors for communicable disease deaths in Pacific Island countries were child and maternal malnutrition (28.32%), followed by unsafe water, sanitation, and handwashing (27.14%), air pollution (16.11%), and unsafe sex (14.96%). There were considerable geographical variations in risk factors. CONCLUSION: The burden of communicable diseases in Pacific Island countries remains high, despite improvements in mortality and disability-adjusted life-year rates over the past few decades. This study provides valuable insights into the burden and trends of communicable diseases in Pacific Island countries from 1990 to 2019. The findings reveal several important insights and highlight the need for targeted public health interventions in the region.

Ensuring access to novel COVID-19 therapeutics in Pacific island countries and areas.

Problem: As of November 2022, over 417 397 confirmed cases and 2631 deaths related to coronavirus disease (COVID-19) were reported in Pacific island countries and areas (PICs). Most PICs have faced challenges accessing therapeutics recommended for the treatment of COVID-19 due to their high demand worldwide and supply chain constraints. Context: The World Health Organization (WHO) coordinates and provides tailored technical and operational support to 21 PICs. Since the start of the pandemic, WHO has worked with partners to establish a mechanism to ensure equitable access to three novel COVID-19 therapeutics (tocilizumab, molnupiravir and nirmatrelvir/ritonavir) for lower-income countries, including 11 eligible PICs. Action: WHO coordinated the requests, procurement and distribution of the three novel therapeutics. In addition, WHO supported PICs by providing trainings in clinical management of COVID-19, developing critical supply needs estimates, and facilitating regulatory approval of clinical therapeutics, including emergency use authorization. Lessons learned: The main barriers to procurement of novel COVID-19 therapeutics were identified as prolonged negotiations with licence holders, sourcing funding, the high cost of therapeutics and limited capacity to provide safety monitoring. Discussion: Uninterrupted supply and availability of essential medicines in the Pacific region is dependent on external and local sourcing. To overcome procurement barriers and ensure access to novel COVID-19 therapeutics in PICs, WHO's pandemic support to Member States focused on strengthening regulatory requirements, safety monitoring and supply chain activities.

Preterm birth among Pacific Islanders in the United States and the US-affiliated Pacific Islands: A systematic review and meta-analysis.

OBJECTIVE: To better understand the epidemiology of preterm birth among Pacific Islanders in the United States and the US-Affiliated Pacific Islands. METHODS: Systematic searches of MEDLINE, Embase, CINAHL, PsycINFO, two nonindexed regional journals, and gray literature were conducted and finalized in September 2021. Observational studies published since January 2010 that documented preterm birth outcomes among Pacific Islanders in the United States and the US-Affiliated Pacific Islands were eligible for inclusion. Outcomes of interest included preterm birth prevalence, risk compared with white women, and risk factors for preterm birth among Pacific Islanders. RESULTS: Fourteen of the 3183 screened articles were included in meta-analyses. Random-effects models were used for pooled estimates with 95% confidence intervals. The pooled prevalence of preterm birth among Pacific Islanders was 11.2%, 95% CI: 9.3%-13.6%. Marshallese women had the highest pooled prevalence (20.7%, 95% CI 18.6%-23.0%) among Pacific Islander subgroups. Compared with white women, Pacific Islander women had higher odds of experiencing preterm birth (OR = 1.40, 95% CI: 1.28-1.53). Four risk factors for preterm birth could be explored with the data available: hypertension, diabetes, smoking, and pre-pregnancy body mass index; hypertension and diabetes significantly increased the odds of preterm birth. CONCLUSIONS: Existing literature suggests that United States Pacific Islanders were more likely to experience preterm birth than white women, although the pooled prevalence varied by Pacific Islander subgroup. Data support the need for disaggregation of Pacific Islanders in future research and argue for examination of subgroup-specific outcomes to address perinatal health disparities.

Epidemiology of tuberculosis in the Pacific island countries and areas, 2000-2020.

Objective: Tuberculosis (TB) is one of the most important infectious diseases with an estimated 9.9 million people falling ill globally in 2020. We describe the epidemiology of TB in the Pacific island countries and areas (PICs) to inform potential priority actions to implement the Western Pacific Regional Framework to End TB 2021-2030. Methods: A descriptive analysis was conducted using annual TB surveillance data submitted by national TB programmes to the World Health Organization (WHO) and TB burden estimates (incidence rates and number of deaths) generated by WHO for the PICs, for the period 2000-2020. We also analysed TB case numbers, multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB), recent risk factor indicators and treatment outcomes. Results: The estimated TB incidence rate in the PICs increased between 2000 and 2020 from 62 to 69 per 100 000 population, with an 8% reduction observed since 2015. TB cases increased by 29% during 2000-2020, with 1746 cases in 2020 and a high proportion in children (19%). Bacteriological diagnosis was used for 58% of total TB cases, although some countries reported clinical diagnoses in over 60% of cases. From 2015 to 2019, 52 MDR/RR-TB cases were reported and there were 94 TB/HIV coinfected cases in 2015-2020. Treatment success was 74% in 2019 due to 18% of cases being unevaluated. In 2020, the estimated proportion of TB cases attributable to smoking, malnutrition, alcohol abuse and diabetes was 17%, 16%, 11% and 9%, respectively. Discussion: There was an increasing trend in TB cases, estimated incidence and deaths between 2000 and 2020. Laboratory services were scaled up in some PICs and case-finding activities greatly contributed to the detection of cases. To end the incidence of TB, continued efforts on case finding, contact investigation and scaling up TB preventive treatment should be prioritized. At the same time, collaboration with other sectors for risk factor management and decentralized management need to be considered.

Pacific Healthy Islands Vision: success factors and challenges faced by health promotion programs.

The World Health Organization's (WHO) Western Pacific Regional Office developed the biennial Healthy Islands Recognition Awards (HIA) in 2009 to reinforce the Healthy Islands vision and encourage countries to continue to innovate and demonstrate effective and efficient ways of promoting and protecting population health. This research aimed to identify characteristics of and challenges for successful health promotion in the Pacific. The research was undertaken to develop practical guidance for other groups in the Pacific Islands interested in supporting Healthy Islands. We used a qualitative case study to review 2013 and 2015 HIA awardees from eight Pacific Island countries and territories using a set of questions drawn from the HIA application criteria. In 2015-2016, 35 key informant interviews and a review of program documents were undertaken. This was followed by a workshop with representatives from three HIA awardees to further develop recommendations. We reviewed eight programs targeting healthy eating, physical activity, healthy settings and sanitation. Using evidence, careful planning, building capacity, developing partnerships, strengthening and reorientating networks, ensuring accountability and conducting evaluation were keys to the success of healthy islands projects. Considering the local setting and community was perhaps the most crucial theme amongst the programs examined. Challenges included funding and capacity constraints, maintaining commitment and prioritisation, maintaining communication and coordination and technical challenges. Success factors, challenges and recommendations aligned well with mainstream health promotion literature, although some important distinctions exist. Further research is needed to guide successful health promotion practice in the Pacific.

Oral Cancer Disparities in the Outer US-affiliated Pacific Islands.

OBJECTIVE/HYPOTHESIS: Oral cancers in the US-affiliated Pacific Islands are poorly described despite disproportionately higher incidences in certain jurisdictions. This study attempts to better characterize the incidence, staging, and management of oral cancers in this region. STUDY DESIGN: Retrospective Epidemiological Study. METHODS: A retrospective review was conducted across the US-affiliated Pacific Islands between 2007 and 2019. Patient data were obtained for individuals with primary head and neck cancers from the Pacific Regional Central Cancer Registry database. All cohorts were age-adjusted to the 2000 US Standard Population. Further analysis was performed on oral cavity cancers due to their clear predominance within the sample. RESULTS: A total of 585 patients with primary head and neck cancers were included. The average age was 54.5 ± 12.9 years, and most patients were male (76.8%). Oral cancer subsite analysis revealed the proportional incidence of buccal mucosa was higher in 5 of 9 jurisdictions when compared with the United States (p < 0.001). Tongue and lip cancers were not found to have significantly higher incidence proportions. Patients in the Pacific Islander group were less likely to be detected at earlier stages for cancers of the cheek and other mouth (p < 0.001), tongue (p < 0.001), and lips (p < 0.001) compared with the United States. CONCLUSIONS: Many Pacific Island populations are burdened with higher incidences of oral cancer with later staging. Further investigation is recommended to evaluate oral cancer-related outcomes and mortality in this region. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1899-1905, 2023.

The tide of dietary risks for noncommunicable diseases in Pacific Islands: an analysis of population NCD surveys.

OBJECTIVE: To describe changes over time in dietary risk factor prevalence and non-communicable disease in Pacific Island Countries (PICTs). METHODS: Secondary analysis of data from 21,433 adults aged 25-69, who participated in nationally representative World Health Organization STEPs surveys in 8 Pacific Island Countries and Territories between 2002 and 2019. Outcomes of interest were changes in consumption of fruit and vegetables, hypertension, overweight and obesity, and hypercholesterolaemia over time. Also, salt intake and sugar sweetened beverage consumption for those countries that measured these. RESULTS: Over time, the proportion of adults consuming less than five serves of fruit and vegetables per day decreased in five countries, notably Tonga. From the most recent surveys, average daily intake of sugary drinks was high in Kiribati (3.7 serves), Nauru (4.1) and Tokelau (4.0) and low in the Solomon Islands (0.4). Average daily salt intake was twice that recommended by WHO in Tokelau (10.1 g) and Wallis and Futuna (10.2 g). Prevalence of overweight/obesity did not change over time in most countries but increased in Fiji and Tokelau. Hypertension prevalence increased in 6 of 8 countries. The prevalence of hypercholesterolaemia decreased in the Cook Islands and Kiribati and increased in the Solomon Islands and Tokelau. CONCLUSIONS: While some Pacific countries experienced reductions in diet related NCD risk factors over time, most did not. Most Pacific adults (88%) do not consume enough fruit and vegetables, 82% live with overweight or obesity, 33% live with hypertension and 40% live with hypercholesterolaemia. Population-wide approaches to promote fruit and vegetable consumption and reduce sugar, salt and fat intake need strengthening.

Assessing the progress on the implementation of policy and legislation actions to address the Non-Communicable Diseases crisis in the Pacific.

AIM: To assess the progress on the implementation of Non-Communicable Diseases (NCD) related policies and legislations in the Pacific Island Countries and Territories (PICTs). MATERIALS AND METHODS: The Pacific Monitoring Alliance for NCD Action (MANA) Dashboard was used to assess the progress on the implementation. The MANA Dashboard includes 31 indicators across four different domains such as leadership and governance; preventative policies and legislations; health system response programs; and monitoring This progress assessment was conducted between 2019 and 2020 for all 21 PICTs. The data were analyzed and compared with the baseline status (2018) report and presented across four different domains of the MANA dashboard. RESULTS: This progress assessment found that PICTs overall have made advancements in a number of areas, particularly the establishment of a national multi-sectoral NCD taskforce; implementation of referenced approaches to restrict trans-fat in the food supply in national documents; and fiscal measures to affect access and availability to less healthy foods and drinks. However, the strengths of actions varied across PICTs, and most are categorised as low strengths. Measures which had the most limited progress in implementation include policy and legislation that restrict alcohol advertising; tobacco industry interference; marketing of foods and non-alcoholic beverages to children; and marketing for breast milk substitutes. CONCLUSIONS: This progress assessment further highlights that while PICTs continue to make progress, NCD policy and legislation gaps still exist, both in terms of weaknesses of existing measures and areas that have had little attention to-date. These require urgent actions to scale up NCD related policies and legislation at regional and national level.

Pacific Islands Cohort on Cardiometabolic Health Study: rationale and design.

BACKGROUND: Pacific Islanders, including those residing in the US Affiliated Pacific Islands (USAPI), experience some of the highest mortality rates resulting from non-communicable diseases (NCDs) worldwide. The Pacific Island Health Officers' Association declared a Regional State of Health Emergency in 2010 due to the epidemic of NCDs in the USAPI. Obesity, a known risk factor for NCDs, has become an epidemic among both children and adults in Micronesia and other parts of the USAPI. There is some recent information about overweight and obesity (OWOB) among young children in the USAPI, but there is no data looking at the relationship between children and their biological parents. The Pacific Islands Cohort on Cardiometabolic Health (PICCAH) Study aims to collect data on NCD lifestyle factors from two generations of families (n = 600 child-parent dyads or 1,200 participants) living in Guam, Pohnpei, and Palau. METHODS: The PICCAH Study is an epidemiological study using community-based convenience sampling to recruit participants in USAPI of Guam, Palau, and Pohnpei. The goal is to recruit participant dyads consisting of 1 child plus their biological parent in Guam (500 dyads or 1,000 participants), Pohnpei (50 dyads or 100 participants), and Palau (50 dyads or 100 participants). All participants are having the following information collected: demographic, health, and lifestyle information; anthropometry; diet; physical activity; sleep; acanthosis nigricans; blood pressure; and serum levels of fasting plasma glucose, fasting insulin, glycated hemoglobin, total cholesterol, triglycerides, LDL, and HDL. DISCUSSION: The PICCAH Study is designed to establish the baseline of a generational epidemiologic cohort with an emphasis on cardiometabolic risk, and to better understand the extent of DM and CVD conditions and related risk factors of those living in the USAPI jurisdictions of Guam, Pohnpei, and Palau. This study also serves to further build research capacity in the underserved USAPI Region.

Historical Malaria Epidemics on Previously Non-Endemic Indo-Pacific Islands.

Islands without prior malaria have on occasion had severe epidemics after its initial introduction, the most infamous example being the Indian Ocean island of Mauritius in 1867. The historical record was examined to see if additional examples of malaria epidemics on Indo-Pacific islands, which were originally non-malarious had been documented. The late nineteenth century depopulation of Polynesian outliers such as Ontong Java has largely been blamed on malaria. Similar but less well-documented instances exist with both the Western Islands, Papua New Guinea, and Rennell in the Solomon Islands. Specific instances of malaria introduction to Grand Comoros and Aldabra Island in the Seychelles occurred by the early twentieth century. In some cases, the epidemics were caused by changes in anopheline vectors while in others new human populations carrying parasites were the important ecological change. It is, however, remarkable how rarely major malaria epidemics have occurred on Indo-Pacific islands.

Progress and strength of response against noncommunicable diseases in the US-affiliated Pacific Island jurisdictions, 2010-2021.

Objective: To determine the effectiveness of the response to the 2010 declared regional noncommunicable diseases (NCDs) emergency in nine US-affiliated Pacific Island jurisdictions. Methods: Vital statistics and risk prevalence surveys were retrospectively reviewed using 14 standardized NCD risk, prevalence and death rate indicators to measure changes in health status over time. NCD risk and prevalence change scores were derived from subsets of these indicators, and NCD composite death rates were examined. An NCD strength-of-intervention score derived from a standardized regional monitoring tool provided measures for assessing responses aimed at curbing risk factors, prevalence and death rates. Associations between the strength-of-intervention score and changes in health status were examined. Results: Pairs of values were available for 97 of 126 individual comparisons for 14 core indicators in nine jurisdictions. The composite mean prevalence of all risk factors across the jurisdictions between baseline and follow-up (26.7% versus 24.3%, P = 0.34) and the composite mean diabetes and hypertension prevalence (28.3% versus 28.2%, P = 0.98) were unchanged, while NCD death rates increased (483.0 versus 521.9 per 100 000 per year, P < 0.01). The composite strength-of-intervention score for the region was 37.2%. Higher strength-of-intervention scores were associated with improvements in health indicators. Discussion: Despite some improvements in selected NCD indicators at the jurisdiction level, there was no significant overall change in the prevalence of risk factors, diabetes and hypertension, and death rates have continued to increase since the NCD emergency declaration. However, the adoption of public sector NCD interventions was associated with improvements in health indicators.