The Protection Gap - Diagnosis, Treatment Status, and Disease Control for People with Diabetes and Hypertension in the US-Affiliated Pacific Islands

Hypertension and diabetes are major causes of disability and mortality in the US-Affiliated Pacific Islands (USAPI). Control of these conditions has the potential to avert much of the burden of non-communicable diseases in the region. To realize this potential, people living with hypertension and diabetes must be identified and receive treatment of sufficient intensity to control their blood pressure and blood glucose. Data from recent cross-sectional surveys conducted in 5 jurisdictions-Pohnpei, Palau, Kosrae, Marshall Islands and American Samoa-were used to estimate the adult prevalence of hypertension and diabetes as well as diagnosis awareness, treatment, and control status of the adults with these conditions. In addition to traditional prevalence indicators, the authors provide a novel presentation of non-communicable disease (NCD) data, using the concept of "protection gaps", defined as the number of people living in a community who have an NCD for which effective control is not attained. The protection gap is determined by applying survey-derived population prevalence estimates to the community's population size using census data. The protection gap is further divided into 3 groups: (1) case-finding gap-those who are unaware of their conditions; (2) tracking and outreach gap-those who are aware of their condition but not receiving treatment; and (3) treatment efficacy gap-those who are receiving treatment but whose disease is not under control. The findings show a large protection gap, with a majority of adults living with hypertension (80.8%) and diabetes (91.6%) not having their condition under control. The case-finding gap accounts for more than half of these, followed by treatment efficacy, and tracking and outreach gaps. These findings can guide public health strategies and monitoring for control of hypertension and diabetes in the USAPI region.

'Hybrid Survey' approach to non-communicable disease surveillance in the US-Affiliated Pacific Islands

In 2010 the US-Affiliated Pacific Islands (USAPI) declared a regional state of health emergency due to the epidemic of non-communicable disease (NCD) and an NCD monitoring and surveillance framework was developed that includes adult NCD risk factor and disease prevalence indicators to be collected every 5 years using a population-based survey. On evaluation of existing data from adult population-based NCD surveys, it was found that there was a lack of valid, available and consistently collected data. Therefore, a new model was developed to combine various indicators and survey tools from different partner agencies into one survey. After the report was endorsed by local health leadership, a dissemination workshop was conducted. In 2015 (baseline for Hybrid Survey implementation), three out of nine jurisdictions (33.3%) had completed a population-based survey in the past 5 years. Four (44.4%) had no adult prevalence data at all, two (22.2%) had data sets from their surveys and four (44.4%) had at least two surveys ever collected that could be used for comparison. As of 2020, all nine jurisdictions have, or are in the process of completing an adult population-based survey. Eight (88.9%) have data sets from their surveys, and five (55.6%) have at least two surveys collected that can be used for comparison. This Hybrid Survey model has helped to improve adult NCD surveillance in the USAPI by more efficiently using limited resources. This model could be considered in other small island nations, or rural areas where adult NCD surveillance is challenging.

Innovations to maximise impact of a data for decision-making training programme in the Federated States of Micronesia

Accurate and timely health information is an essential foundation for strengthening health systems. Data for decision making (DDM) is a training curriculum designed to enhance capacity of health department staff to capture and use high-quality data to address priority health issues. In 2013, the Pacific Public Health Surveillance Network adapted and piloted the DDM curriculum as an 'at work, from work, for work' field epidemiology training programme component for low-income and middle-income Pacific Island jurisdictions. Based on lessons learned from the pilot, we made several innovations, including delivery on-site at each district (rather than bringing trainees to a central location), conducting pre-DDM consultations and ongoing contact with health leaders across the programme, taking more care in selecting trainees and enrolling a larger cohort of students from within each health department. The decentralised programme was delivered in-country at four sites (both at national and state levels) in the Federated States of Micronesia. Following delivery, we performed an external evaluation of the programme to assess student outcomes, benefits to the health department and general programme effectiveness. Of the 48 trainees who completed all four classroom modules, 40 trainees participated in the evaluation. Thirty-two of these trainees completed the programme's capstone field project. Eighteen of these projects directly contributed to changes in legislation, revised programme budgets, changes in programme strategy to augment outreach and to target disease and risk factor 'hot spots'.

Characterization of Agfa Structurix series D4 and D3sc x-ray films in the 0.7-4.6 keV energy range

X-ray films remain a key asset for high-resolution x-ray spectral imaging in high-energy-density experiments conducted at the National Ignition Facility (NIF). The soft x-ray Opacity Spectrometer (OpSpec) fielded at the NIF has an elliptically shaped crystal design that measures x rays in the 900-2100 eV range and currently uses an image plate as the detecting medium. However, Agfa D4 and D3sc x-ray films' higher spatial resolution provides increased spectral resolution to the data over the IP-TR image plates, driving the desire for regular use of x-ray film as a detecting medium. The calibration of Agfa D4 x-ray film for use in the OpSpec is communicated here. These calibration efforts are vital to the accuracy of the NIF opacity measurements and are conducted in a previously un-studied x-ray energy range under a new film development protocol required by NIF. The absolute response of Agfa D4 x-ray film from 705 to 4620 eV has been measured using the Nevada National Security Site Manson x-ray source. A broader range of energies was selected to compare results with previously published data. The measurements were taken using selected anodes, filters, and applied voltages to produce well-defined energy lines.

Upgrades and redesign of the National Ignition Facility's soft x-ray opacity spectrometer (OpSpec)

The soft x-ray Opacity Spectrometer (OpSpec) used on the National Ignition Facility (NIF) has recently incorporated an elliptically shaped crystal. The original OpSpec used two convex cylindrical crystals for time-integrated measurements of point-projection spectra from 540 to 2100 eV. However, with the convex geometry, the low-energy portion of the spectrum suffered from high backgrounds due to scattered x-rays as well as reflections from alternate crystal planes. An elliptically shaped crystal allows an acceptance aperture at the crossover focus between the crystal and the detector, which reduces background and eliminates nearly all reflections from alternate crystal planes. The current elliptical design is an improvement from the convex cylindrical design but has a usable energy range from 900 to 2100 eV. In addition, OpSpec is currently used on 18 NIF shots/year, in which both crystals are typically damaged beyond reuse, so efficient production of 36 crystals/year is required. Design efforts to improve the existing system focus on mounting reliability, reducing crystal strain to increase survivability between mounting and shot time, and extending the energy range of the instrument down to 520 eV. The elliptical design, results, and future options are presented.

Baseline status of policy and legislation actions to address non communicable diseases crisis in the Pacific

BACKGROUND

Non-Communicable Diseases (NCD) are the leading cause of death in the Pacific Island Countries and Territories (PICTs) accounting for approximately 70% of mortalities. Pacific leaders committed to take action on the Pacific NCD Roadmap, which specifies NCD policy and legislation. To monitor progress against the NCD Roadmap, the Pacific Monitoring Alliance for NCD Action (MANA) was formed and the MANA dashboard was developed. This paper reports on the first status assessment for all 21 PICTs.

METHODS

The MANA Dashboard comprises 31 indicators across the domains of leadership and governance, preventive policies, health system response and monitoring processes, and uses a 'traffic light' rating scheme to track progress. The dashboard indicators draw on WHO's best-buy interventions and track highly cost-effective interventions for addressing NCDs. The MANA coordination team in collaboration with national NCD focal points completed Dashboards for all 21 PICTs between 2017 and 2018 in an agreed process. The data were analysed and presented within each area of the MANA dashboard.

RESULTS

This assessment found that PICTs are at varying stages of developing and implementing NCD policy and legislation. Some policy and legislation are in place in most PICTs e.g. smoke free environment (18 PICTs), alcohol licensing (19 PICTs), physical education in schools (14 PICTs), reduction of population salt consumption (14 PICTs) etc. However, no PICTs has policy or legislation on tobacco industry interference, controlling marketing of foods and drinks to children, and reducing trans-fats in the food supply, and only 7 PICTs have policies restricting alcohol advertising. Eighteen PICTs implement tobacco taxation measures, however only five were defined as having strong measures in place. Nineteen PICTs have alcohol taxation mechanisms and 13 PICTs have fiscal policies on foods to promote healthier diets.

CONCLUSION

This baseline assessment fills a knowledge gap on current strengths and areas where more action is needed to scale up NCD action in a sustained 'whole of government and whole of society approach' in PICTs. The findings of this assessment can be used to identify priority actions, and as a mutual accountability mechanism to track progress on implementation of NCD policy and legislation at both national and Pacific level.

High Prevalence of Non-Communicable Disease Risk Factors among Adolescents in Pohnpei, Micronesia

Non-communicable disease (NCD) related behaviors among adolescents are on the rise globally and in the Pacific region. To better understand and elucidate the prevalence of NCD risk factors among adolescents in Pohnpei state, Federated States of Micronesia, a cross-sectional study was conducted among secondary school students. Of 2965 students enrolled in the 2015-2016 academic year, 2555 (86.2%) completed the survey, and 2386 (80.5%) were included in the final analysis. Of the survey respondents, 21.7% of students self-reported smoking tobacco in the past 30 days, 30.3% self-reported drinking alcohol in the past 30 days, 40.9% self-reported chewing betel nut in the past 30 days, and 21.2% self-reported chewing tobacco with or without betel nut in the last 30 days. Male students, older students, and public school students had higher prevalence of substance use. Additionally, about 17.3% of students were overweight and 10.1% were obese according to physical measures of height and weight. Female students and private school students had higher prevalence of overweight and obesity than male students, and prevalence of overweight was higher in older age groups. These findings indicate a cohort of adolescents at substantial risk for the development of NCDs and signal an urgent need for public health interventions to address NCD risk factors.

Research ethics committees in the Pacific Islands: gaps and opportunities for health sector strengthening

There has been a range of developments in recent years to stimulate increasing public health research activity throughout the Pacific. Development of local capacity for ethics committee review and oversight is, however, frequently underdeveloped. This is reflected in the number of Pacific Island nations where ethics committees have not been established or where only informal processes exist for ethics review and oversight. This is problematic for the optimal development of relevant and culturally appropriate research, and building up local ethics committees should be part of continued research development in the Pacific. Three areas in which local ethics committees may add value are 1) offering better capacity to reflect local priorities, 2) providing broader benefits for research capacity building, and 3) assisting to strengthen systems beyond research ethics. This article considers benefits and challenges for ethics committees in the Pacific, and suggests directions for regional development to further strengthen public health research activity.

Monitoring and accountability for the Pacific response to the non-communicable diseases crisis

Background

Non-communicable diseases (NCD) are the leading cause of premature death and disability in the Pacific. In 2011, Pacific Forum Leaders declared “a human, social and economic crisis” due to the significant and growing burden of NCDs in the region. In 2013, Pacific Health Ministers’ commitment to ‘whole of government’ strategy prompted calls for the development of a robust, sustainable, collaborative NCD monitoring and accountability system to track, review and propose remedial action to ensure progress towards the NCD goals and targets. The purpose of this paper is to describe a regional, collaborative framework for coordination, innovation and application of NCD monitoring activities at scale, and to show how they can strengthen accountability for action on NCDs in the Pacific. A key component is the Dashboard for NCD Action which aims to strengthen mutual accountability by demonstrating national and regional progress towards agreed NCD policies and actions.

Discussion

The framework for the Pacific Monitoring Alliance for NCD Action (MANA) draws together core country-level components of NCD monitoring data (mortality, morbidity, risk factors, health system responses, environments, and policies) and identifies key cross-cutting issues for strengthening national and regional monitoring systems. These include: capacity building; a regional knowledge exchange hub; innovations (monitoring childhood obesity and food environments); and a robust regional accountability system.

The MANA framework is governed by the Heads of Health and operationalised by a multi-agency technical Coordination Team. Alliance membership is voluntary and non-conditional, and aims to support the 22 Pacific Island countries and territories to improve the quality of NCD monitoring data across the region. In establishing a common vision for NCD monitoring, the framework combines data collected under the WHO Global Framework for NCDs with a set of action-orientated indicators captured in a NCD Dashboard for Action.

Summary

Viewing NCD monitoring as a multi-component system and providing a robust, transparent mutual accountability mechanism helps align agendas, roles and responsibilities of countries and support organisations. The dashboard provides a succinct communication tool for reporting progress on implementation of agreed policies and actions and its flexible methodology can be easily expanded, or adapted for other regions.

Mapping HPV Vaccination and Cervical Cancer Screening Practice in the Pacific Region-Strengthening National and Regional Cervical Cancer Prevention

OBJECTIVE

To provide background information for strengthening cervical cancer prevention in the Pacific by mapping current human papillomavirus (HPV) vaccination and cervical cancer screening practices, as well as intent and barriers to the introduction and maintenance of national HPV vaccination programmes in the region.

MATERIALS AND METHODS

A cross-sectional questionnaire-based survey among ministry of health officials from 21 Pacific Island countries and territories (n=21).

RESULTS

Cervical cancer prevention was rated as highly important, but implementation of prevention programs were insufficient, with only two of 21 countries and territories having achieved coverage of cervical cancer screening above 40%. Ten of 21 countries and territories had included HPV vaccination in their immunization schedule, but only two countries reported coverage of HPV vaccination above 60% among the targeted population. Key barriers to the introduction and continuation of HPV vaccination were reported to be: (i) Lack of sustainable financing for HPV vaccine programs; (ii) Lack of visible government endorsement; (iii) Critical public perception of the value and safety of the HPV vaccine; and (iv) Lack of clear guidelines and policies for HPV vaccination.

CONCLUSION

Current practices to prevent cervical cancer in the Pacific Region do not match the high burden of disease from cervical cancer. A regional approach, including reducing vaccine prices by bulk purchase of vaccine, technical support for implementation of prevention programs, operational research and advocacy could strengthen political momentum for cervical cancer prevention and avoid risking the lives of many women in the Pacific.

Structure and magnetism in LaCoO3

The temperature dependence of the hexagonal lattice parameter c of single crystal LaCoO3(LCO) with H = 0 and 800 Oe, as well as LCO bulk powders with H = 0, was measured using high-resolution x-ray scattering near the transition temperature To ≈35 K. The change of c(T) is well characterized by a power law in T − To for T>To and by a temperature independent constant for T<To when convoluted with a Gaussian function of width 8.5 K. This behavior is discussed in the context of the unusual magnetic behavior observed in LCO as well as recent generalized gradient approximation calculations.

Structure and magnetism in LaCoO3

The temperature dependence of the hexagonal lattice parameter c of single crystal LaCoO3(LCO) with H = 0 and 800 Oe, as well as LCO bulk powders with H = 0, was measured using high-resolution x-ray scattering near the transition temperature To ≈35 K. The change of c(T) is well characterized by a power law in T − To for T>To and by a temperature independent constant for T<To when convoluted with a Gaussian function of width 8.5 K. This behavior is discussed in the context of the unusual magnetic behavior observed in LCO as well as recent generalized gradient approximation calculations.

The unusual magnetism of nanoparticle LaCoO3

Bulk and nanoparticle powders of LaCoO3 (LCO) were synthesized and their magnetic and structural properties were studied using SQUID magnetometry and neutron diffraction. The bulk and large nanoparticles exhibit weak ferromagnetism (FM) below T ≈ 85 K and a crossover from strong to weak antiferromagnetic (AFM) correlations near a transition expressed in the lattice parameters, To≈40 K. This crossover does not occur in the smallest nanoparticles; instead, the magnetic behavior is predominantly ferromagnetic. The amount of FM in the nanoparticles depends on the amount of Co3O4 impurity phase, which induces tensile strain on the LCO lattice. A core-interface model is introduced, with the core region exhibiting the AFM crossover and with FM in the interface region near surfaces and impurity phases.

Magnetism and phase transitions in LaCoO3

Neutron scattering and magnetometry measurements have been used to study phase transitions in LaCoO3 (LCO). For H ≤ 100 Oe, evidence for a ferromagnetic (FM) transition is observed at Tc ≈ 87 K. For 1 kOe ≤ H ≤ 60 kOe, no transition is apparent. For all H, Curie-Weiss analysis shows predominantly antiferromagnetic (AFM) interactions for T > Tc, but the lack of long-range AFM order indicates magnetic frustration. We argue that the weak ferromagnetism in bulk LCO is induced by lattice strain, as is the case with thin films and nanoparticles. The lattice strain is present at the bulk surfaces and at the interfaces between the LCO and a trace cobalt oxide phase. The ferromagnetic ordering in the LCO bulk is strongly affected by the Co-O-Co angle (γ), in agreement with recent band calculations which predict that ferromagnetic long-range order can only take place above a critical value, γC. Consistent with recent thin film estimations, we find γC = 162.8°. For γ > γC, we observe power-law behavior in the structural parameters. γ decreases with T until the critical temperature, To ≈ 37 K; below To the rate of change becomes very small. For T < To, FM order appears to be confined to regions close to the surfaces, likely due to the lattice strain keeping the local Co-O-Co angle above γC.

A primer for quality assurance and improvement in Pacific island health services

Quality assurance and improvement (QA/QI) systems are underdeveloped in Pacific island jurisdictions and building QA/QI capacity is one of the best opportunities for quickly improving performance of health services in the region. There is a variety of styles available for QA/QI in health care organizations and the best approach will vary with the size, scope of practice, and needs of the organization. This report briefly describes the major styles of QA/QI and provides suggestions for QA/QI program approach based on several common Pacific island scenarios.

Quality improvement and the hierarchy of needs in low resource settings: perspective of a district health officer

District services in developing countries are afflicted with frequent system breakdowns, caused by a combination of resource constraints, limitations of the health workforce, and poorly developed management systems. Narrowly focused, outcome-oriented quality improvement initiatives and sporadic accreditation visits fail to address the most pressing need of district health services- to improve manageability. To improve quality at the district level, attention should be directed first toward this need- by building widely focused systems for ongoing, operational monitoring and response.

Yap assessment for a continuing health care professional development program

In 2003, the University of Hawai'i Department of Family Medicine and Community Health entered a 4-year cooperative agreement with the U.S. Health Resources and Services Administration to establish the "Pacific Association for Clinical Training" (PACT). PACT's goal is to develop effective distance education methods to improve the education and skills of healthcare professionals in the U.S.-Affiliated Pacific Island nations. To determine the situation existing in 2004, one of PACT's first projects was to perform site visits to each jurisdiction, conducting needs assessments through interviews with key health care professionals, hospital administrators, and government officials. This article highlights findings of PACT's assessment of YAP State, Federated States of Micronesia. Meant to establish a baseline for future reference, all data are those collected in 2004/2005 and have not been updated.

The Yap AHEC: an update 2002-2006

The Yap Area Health Education Center (AHEC) is one of three U.S. Health Resources and Services Administration-funded AHEC programs in the U.S.-Affiliated Pacific Island jurisdictions (together with those in Palau and the Commonwealth of the Northern Mariana Islands). The Pacific Island AHECs are administered through the University of Hawai'i, John A. Burns School of Medicine and were founded in response to recommendations for development of the local health workforce by the U.S. Institute of Medicine in its 1998 report, "Pacific Partnerships for Health". The goal of the Yap AHEC is to build human capacity in the health workforce, and thereby strengthen the health service and improve health status for the people of Yap State. An ancillary goal is to pilot test new approaches to health workforce development, which might be shared with others in the region. These goals have been pursued by building partnerships with colleges in the region, with the new Wa'ab Community Health Center project in Yap and the Yap State Department of Health Services to bring formal college programs for students and health service staff to Yap State. To date, formal relationships have been established with five colleges; Palau Community College (PCC), the College of Micronesia-Federated States of Micronesia (FSM), Fiji School of Medicine (Department of Public Health & Primary Care), University of Hawai'i, Hilo, and the University of Alaska, Anchorage. A total of 143 students have been enrolled in 48 courses in several health worker disciplines, including clinical nurses, health assistant/dispensary managers, community health outreach workers, public health program staff pharmacy technicians and x-ray technicians. In addition to facilitating the delivery of courses in Yap, a new 6-course certificate program has been developed for community outreach workers in collaboration with the College of Micronesia, FSM and the Wa'ab Community Health Center (Wa'ab CHC) in order to support the CHC's innovative health service delivery model. The Yap AHEC has also assisted the College of Micronesia-FSM in the World Health Organization sponsored development of a proposal for the establishment of a nursing program, which is based on the decentralized, on-site (DC-OS) nursing training model that has been pilot tested in partnership with PCC at Yap State Hospital.

Ulithi Atoll health assessment: a peek at the health of rural Micronesia

BACKGROUND

The health challenges of Micronesians are generally well known. However most of the health-related data collection occurs in the population centers and relatively little is known about the health of the residents of Micronesia's rural outer islands. This is of particular concern in the Federated States of Micronesia (FSM) where a large portion of the population lives on the outer islands. To gain a better understanding of the health issues facing the isolated outer islands of Micronesia, a health survey was performed on Ulithi Atoll in Yap, FSM.

METHODS

A survey was created by the Yap State Department of Health Services and members of the Ulithian community. The survey was carried out on two of the four inhabited islands of Ulithi Atoll in July 2004. Both island communities actively participated in the survey providing translation and data gathering assistance.

RESULTS

It was estimated that a >90% response rate for both islands was achieved. Analysis demonstrated that relative to the U.S., the Atoll's population experienced high rates of obesity (45%), hypertension (29%), and smoking (55%). Sixty-six percent of men surveyed reported alcohol use versus 16% of women. Use of alcohol was markedly lower on Fatharai Island where a Chief had mandated abstinence. Preventative health screening was limited with over 80% of women having pap smear in the past 2 years. In addition, the community identified finances and transportation as the main difficulties in accessing healthcare.

CONCLUSION

Overall, the research identified a number of health issues that require closer attention, in particular hypertension, overweight, obesity, alcohol misuse, smoking prevalence, betel nut/ tobacco chewing, and domestic violence. There is indication that the community may be ready to address some of these issues. The value of community action within cultural frameworks is apparent, and there may be potential to extend culturally-based approaches to address a broader range of issues.

Interdisciplinary problem-based learning as a method to prepare Micronesia for public health emergencies

CONTEXT

The University of Hawai'i Pacific Basin Bioterrorism Curriculum Development Project has developed a problem-based learning (PBL) curriculum for teaching health professionals and health professional students about bioterrorism and other public health emergencies. These PBL cases have been incorporated into interdisciplinary training settings in community-based settings, such as in the small island districts of the U.S.-Affiliated Pacific Islands.

METHODS

Quantitative and qualitative methods have been utilized in the evaluation of the PBL cases, PBL tutorials, and the accomplishment of learning objectives.

FINDINGS

Evaluation of the PBL tutorials demonstrates that PBL is an educational and training modality appropriate for such settings. Participants found it helpful to learn in interdisciplinary groups. The educational process was modified in accordance with local culture.

CONCLUSION

PBL is a useful educational modality for settings where healthcare staffing and available resources are limited.

Scrub typhus, Republic of Palau

Scrub typhus is likely endemic in Palau.

Scrub typhus, caused by Orientia tsutsugamushi, is a severe febrile illness transmitted to humans by trombiculid mites, which normally feed on rodents. The first known outbreak of scrub typhus in Palau occurred in 2001 to 2003 among residents of the remote southwest islands. To determine the extent of scrub typhus distribution in Palau, we tested serum samples from humans and rodents for antibodies to O. tsutsugamushi. Of 212 Palau residents surveyed in 2003, 101 (47.6%) had immunoglobulin G (IgG) antibody titers >1:64, and 56 (26.4%) had concurrent IgG and IgM antibody titers >1:512 and 1:64, respectively. Of 635 banked serum samples collected from Palau residents in 1995, 34 (5.4%) had IgG antibody titers >1:64. Sera collected from rodents (Rattus norvegicus and R. rattus) in 2003 and 2005 were tested, and 18 (28.6%) of 63 had IgG antibody titers >1:64. These findings suggest that scrub typhus is endemic in Palau.

Acaricide efficiency of amitraz / cypermethrin and abamectin pour-on preparations in game

The efficacy of an amitraz / cypermethrin pour-on preparation (1 % w/v each) was tested against natural tick infestations of buffaloes, eland and blesbok in three separate trials. The eland were also treated with a 0.02 % abamectin (w/v) acaricidal pour-on preparation. The amitraz / cypermethrin pour-on was effective against Amblyomma hebraeum, Rhipicephalus evertsi evertsi, Rhipicephalus appendiculatus and Hyalomma marginatum rufipes on the buffaloes. Both acaricides were effective against R. appendiculatus and Rhipicephalus (Boophilus) decoloratus in the eland. The amitraz / cypermethrin acaricide was effective against R. (Boophilus) decoloratus in the blesbok. Ticks can cause damage to the skins, secondary infections, abscesses, anaemia, loss of condition, tick toxicosis and act as vectors of infectious diseases. Introduction of hosts and / or ticks from endemic to non-endemic areas because of translocation of game, may lead to severe losses. The pouron acaricides tested were effective against natural tick infestations and should always be used according to the manufacturer's instructions and efficacy claims.

The Palau AHEC--academizing the public health work plan: capacity development and innovation in Micronesia

The Palau Area Health Education Center (AHEC)--a program of the University of Hawaii's John A. Burns School of Medicine (JABSOM) and based at Palau Community College--was established in 2001 in response to the recommendations of the 1998 Institute of Medicine (IOM) report--Pacific Partnerships for Health--Charting a New Course for the 21st Century1. One of IOM's core recommendations was to promote the training of the primary health care workforce among the U.S.-Associated Pacific Islands. Since its inception in 2001, the Palau AHEC has coordinated overall 37 postgraduate and undergraduate courses in General Practice and Public Health taught by the University of Auckland Faculty of Medicine and Health Sciences and the Fiji School of Medicine's School of Public Health and Primary Care (SPH&PC) in Palau, Yap State, and the Republic of the Marshall Islands. Currently 139 physicians, nurses, health administrators, and environmental health workers are registered as active students in Palau (58), Yap State (22), and the RMI (59). Notably, the Palau AHEC and the SPH&PC have worked in an innovative partnership with the Palau Ministry of Health to operationalize the MOH's public health work plan to implement a comprehensive community health survey of all 4,376 households in Palau, interviewing 79% of the total population, to determine Palau's health indicators. To accomplish this, the SPH&PC developed and taught a curriculum for Palau physicians and public health nurses on how to design the survey, gather, and analyze data in order to develop and implement appropriately responsive intervention and treatment programs to address Palau's old and newer morbidities. In early FY2005, two other Micronesian AHECs--the Yap State and Commonwealth of the Northern Mariana Islands AHECs--were funded through JABSOM administered grants which will also address the primary care training needs of Micronesia's remote and isolated health workforce.

The use of appropriateness criteria for the selection of clinical preventive services for a Pacific island health service

Clinical preventive services are measures performed in the clinic setting for the prevention of disease and the promotion of health. The general practice/public health physician residency class of the Palau Area Health Education Center reviewed existing clinical preventive services protocols for the Ministry of Health of the Republic of Palau and revised them, taking four criteria into consideration for each candidate intervention (local patterns of disease and risk factors, evidence for effectiveness of the intervention, local system capability for delivery of the intervention and its consequences, and competing priorities). The resulting package of interventions is much more focused and appropriate to local conditions than was the one that it replaced. It has the potential to improve the health status of the population by making better use of available resources.

Scrub typhus in the Republic of Palau, Micronesia

In October 2001, an outbreak of febrile illness began in the southwest islands group of the Republic of Palau. Through October 2003, a total of 15 southwest islanders experienced fever >39.5 degrees C and abdominal distress, both lasting >7 days. Orientia tsutsugamushi, the agent of scrub typhus, was subsequently identified as the cause.

Cancer in Yap State, Federated States of Micronesia

Little is known about the impact of cancer and the extent of cancer-related services in Yap. The purpose of this study, funded by the National Cancer Institute, was to document the state of cancer awareness and services in Yap and to prioritize cancer-care needs. Findings suggest that cancer is the leading cause of death in Yap, yet cancer-related awareness, prevention, detection, and treatment services are limited. A number of needs were identified, and an action plan was developed based on five priority areas: 1) establishing a cancer registry; 2) increasing awareness of cancer risk, prevention, and detection; 3) expanding cancer screening and detection programs; 4) expanding cancer-related training opportunities for clinical staff; and 5) purchasing cancer-related equipment & supplies.

In-country and community-based postgraduate family practice training for Micronesian physicians--the Palau AHEC: a collaborative effort

The U.S. Institute of Medicine in its 1998 review of the health care systems among the U.S.-Associated Pacific Islands (USAPI) identified promotion of primary health care (PHC) and training of the regional health workforce including postgraduate training for physicians as priorities. With the support of the health leadership of the USAPI and the Republic of Palau, the John A. Burns School of Medicine (JABSOM) of the University of Hawaii captured U.S. federal Area Health Education Center (AHEC) funds to implement a postgraduate program to train Family Practitioners - physician specialists in primary care for the region. The Palau AHEC has evolved into ajoint activity of JABSOM, the University of Auckland Faculty of Medicine and Health Sciences (UAFMHS), the School of Public Health & Primary Care--Fiji School of Medicine, and Palau Community College to provide Diploma-level training in Family Practice and Community Health for Micronesian physicians.

Diabetes in the indigenous population of the Commonwealth of the Northern Mariana Islands

Diabetes prevalence and complications rates were examined for the indigenous population of the Commonwealth of the Northern Mariana Islands in the western Pacific. Diabetes is common, with 4% of the population and 11% of adults having diagnosed diabetes. Diabetes is more common among females and islanders of Carolinian descent. End stage renal disease, hospitalizations for pneumonia, non-traumatic lower extremity amputations and retinopathy are more common than expected (with relative risks of 3.9, 3.0, 1.5 and 1.3, respectively, compared with diabetics in US), while diabetes-related mortality and hospitalizations for ischemic heart disease/cerebrovascular disease are less (with relative risks of 0.9 and 0.8). Implications for primary and secondary prevention of diabetes and its complications are discussed.

Childhood vitamin A status and the risk of otitis media

BACKGROUND

It has been suggested that vitamin A deficiency may predispose to otitis media.

METHODS

We conducted a prospective, observational study of 200 children, ages 3 to 5 years, on the island of Saipan in the Commonwealth of the Northern Mariana Islands. Baseline measurements of serum retinol concentrations were obtained from the children, and incidence of otitis media was determined during the following year by review of medical records. The sera were also tested for concentration of other carotenoids (beta-carotene, alpha-carotene, lutein and zeaxanthin, beta-cryptoxanthin, lycopene), and alpha-tocopherol and baseline concentrations of these compounds were also examined for relationship to incidence of otitis media.

RESULTS

Serum retinol concentrations of the children ranged from 13 to 58 microg/dl. Episodes of otitis media occurred in 22% of children during the follow-up period. Children with low serum retinol concentrations did not have an excess of episodes of otitis media (chi square for trend, 0.438; P = 0.508 for children grouped by serum retinol concentration; mean serum retinol concentrations were 29.1 and 28.6 microg/dl, respectively, for children who had and did not have a subsequent episode of otitis media). Controlling for potential confounding variables (duration of breast feeding, smoking in the household, illness or live virus vaccination in the 2 weeks before serum collection, day-care attendance) did not substantially alter this finding. Baseline serum concentrations of the other carotenoids and alpha-tocopherol also demonstrated no relation to incidence of otitis media.

CONCLUSION

In the range of serum vitamin concentrations found in this population, the status of vitamin A and related compounds in children appeared to have no effect on the incidence of otitis media.

Salmonella isolated from feeds and feed ingredients during the period 1982-1988: animal and public health implications

The prevalence of Salmonella in southern Africa in farm feeds and by-products of animal origin during 1982-1988 was determined. Salmonella occurred in 5.18% of the farm feed samples and in 9.54% of the by-product samples. Different serovars were isolated, some only once. The findings underestimate the true prevalence of Salmonella in farm feeds and by-products, and is representative of only the most severely contaminated products. The epidemiology of salmonellosis is discussed with special reference to the importance of multiple resistance to antibiotics, the increase in the number of cases of salmonellosis worldwide and "Salmonella free" feeds and foods. More detailed research on the role of farm feeds in the epidemiology of salmonellosis is required. Efforts should be made to increase awareness of the problem, to improve quality management at farm feed production plants and to develop efficient systems to monitor the hygienic safety of feeds and foods.

Resistance to various antibiotics of Salmonella and Escherichia coli isolated from registrable farm feeds

Resistance to 20 antibiotics of 128 Salmonella and 97 Escherichia coli isolates from various registrable farm feeds was determined. A high frequency of comparatively low levels of resistance was found in both the Salmonella and E. coli isolates. This, together with an elevated frequency of multiple resistance, indicates that problems related to an effective transfer in bacterial populations of resistance to certain antibiotics are a distinct possibility. The addition of antibiotics, such as penicillin and tetracyclines, to animal feeds can create conditions for rapid selection amongst bacteria resistant to antibiotics. The numbers of resistant bacteria in the animal environment may be increased and may lead to the development of veterinary and human health problems from the possible transfer of antimicrobial resistance from animal pathogens to human pathogens or spreading in the human population of animal pathogens resistant to antibiotics. There is a need for caution in the use of antibiotics, particularly in animal feeds. Extended survey of, and epidemiological research on, farm feeds, manufacturing mills and animal production units are emphasized.

Electron microscopic observations on the luminal surface of teat cup liners of milking machines used under South African conditions

An investigation undertaken with the aid of scanning electron microscopy (SEM) on new and used teat cup liners revealed the generally poor quality of luminal surfaces. Even those of the brand-new distributor controls showed significant faults in the evenness and continuity of the liner surface. A hundred and 500 milkings apparently tend to aggravate faults like cracks, pores, grooves and pits, because of the general brittleness of some of the teat cup liners. The poor quality of the liners investigated raises various questions about the method of distribution of teat cup liners and serious concern about the role they play in predisposing bovine udders to mastitogenic infections, spreading mastitis, affecting the production and quality of milk, increasing the cost of milk production and reducing profits of dairy farming.

Fluctuations in the glucose level of cow's milk from normal and subclinically diseased udders

Individual quarter samples from some 19 cows on average were investigated monthly over 12 months for determining the udder health status of cows and the glucose concentrations of foremilk and strippings. Foremilk showed a mean 0,1311 mM concentration of glucose which remained fairly stable during the period of investigation and lactation. A fluctuating mean value of 0,2037 mM was determined in strippings in which glucose levels were consistently and appreciably higher than those of foremilk. Foremilk from completely normal quarters and others affected by non-specific cellular reaction, relevant or irrelevant teat canal infection and aseptic or septic subclinical mastitis, showed mean glucose concentrations of 0,1410; 0,1392; 0,1337; 0,1417; 0,1262 and 0,1248 mM, respectively. Strippings from the same quarters showed corresponding values of 0,2056; 0,2861; 0,2100; 0,1733; 0,1661 and 0,1617 mM glucose.

Ultrastructural aspects of the liver perisinusoidal space in diabetic patients with and without microangiopathy

To determine whether abnormalities of the perisinusoidal space of Disse are present in the liver of diabetic patients with microangiopathy, an ultrastructural stereologic study of the space of Disse was performed in six insulin-treated diabetics with severe performed in six insulin-treated diabetics with severe proliferative retinopathy and six insulin-treated diabetics with normal fluorescein angiography, six patients with familial unconjugated hyperbilirubinemia were studied as controls. No patient had clinical and/or biochemical hepatic abnormalities and none suffered from any of the pathologic conditions known to be associated with collagenization of the perisinusoidal space. In control patients, the space of Disse of liver sinusoids contained occasional small deposits of collagen fibers. The relative volume of these fibers per unit of sinusoid represented 2.63 +/- 0.82%. In all diabetic patients with retinopathy, marked deposition of collagen fibers within the perisinusoidal space was constantly observed, a finding confirmed by ultrastructural stereologic analysis which showed that the relative volume of collagen fibers per unit of sinusoid represented 7.33 +/- 1.44% and differed significantly from control patient values (P less than 0.001). On the contrary, the relative volume of collagen fibers within the space of Disse in diabetic patients without retinopathy (3.95 +/- 2.96%) did not differ significantly from control patient values. These findings demonstrate that collagenization of the space of Disse is positively correlated with the presence of diabetic microangiopathy. Ultrastructural examination of the liver sinusoids might constitute a sensitive and useful approach for detecting the early changes of the microcirculation in diabetic patients.

Differentiation of Serratia from Enterobacter on the basis of nucleoside phosphotransferase production

Precoated cellulose thin-layer chromatograms were used to detect the production of guanosine 5'-phosphate from guanosine and p-nitrophenylphosphate by whole-cell preparations. One-hundred per cent of Serratia (163 strains) and 84% of E. liquefaciens (15 of 18 strains) produced the nucleotide. All other Enterobacter (23 strains), Klebsiella (10 strains), and E. coli (10 strains) were negative for the production of this nucleotide. The entire test procedure could be carried out in 4 hr. It is proposed that E. liquefaciens is more closely related to Serratia than Enterobacter and that reclassification of these organisms should be investigated.