HUI: Beautiful scars

This article is the written account of a discussion between a group of indigenous women (trained both in Western and Indigenous knowledge systems), on the relevance of diagnosis in their conceptualisations of health and illness.

Characterizing pathways of seafood access in small island developing states

Ensuring healthy and sustainable food systems in increasing social, economic, and ecological change is a key global priority to protect human and environmental health. Seafood is an essential component of these food systems and a critical source of nutrients, especially in coastal communities. However, despite rapid transformations in aquatic food systems, and our urgent need to understand them, there is a dearth of data connecting harvested food production to actualized food consumption. Many analyses suggest institutional, legal, or technological innovations to improve food systems, but few have analyzed the pathways through which people already gain access to nutritious food. Here, using a random forest model and cluster analysis of a nationally representative data set from Kiribati, we operationalize access theory to trace the flows of consumptive benefit in a fisheries-based food system. We demonstrate that the market access mechanism is the key mechanism mediating seafood access in Kiribati, but importantly, the highest seafood consumption households showed lower market access, pointing to the importance of non-market acquisition (e.g., home production and gifting). We reveal six distinct household strategies that employ different sets of access mechanisms to ensure high levels of local seafood consumption in different contexts. We demonstrate the impacts of these strategies on the composition of household seafoods consumed, stressing the need to support these existing successful strategies. Finally, we point to key policy and management insights (e.g., improved infrastructure, shifts in species management) that may be more effective in reinforcing these existing pathways than commonly proposed food system interventions.

Type 2 Diabetes Prevalence, Control and Management within Fiji, Kiribati, Samoa, the Solomon Islands, Tonga, and Vanuatu: A Scoping Review 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.

Effectiveness of population-wide screening and mass drug administration for leprosy control in Kiribati: the COMBINE protocol

INTRODUCTION

Progress towards leprosy elimination is threatened by increasing incidence in 'hot-spot' areas where more effective control strategies are urgently required. In these areas, active case finding and leprosy prevention limited to known contacts is insufficient for control. Population-wide active case-finding together with universal prevention through mass drug administration (MDA) has been shown to be effective in 'hot-spot' areas, but is logistically challenging and expensive. Combining leprosy screening and MDA with other population-wide screening activities such as for tuberculosis may increase programme efficiency. There has been limited evaluation of the feasibility and effectiveness of combined screening and MDA interventions. The COMBINE study aims to bridge this knowledge gap.

METHODS AND ANALYSIS

This implementation study will assess the feasibility and effectiveness of active leprosy case-finding and treatment, combined with MDA using either single-dose rifampicin or rifamycin-containing tuberculosis preventive or curative treatment, for reducing leprosy incidence in Kiribati. The leprosy programme will run over 2022-2025 in concert with population-wide tuberculosis screening-and-treatment in South Tarawa. The primary research question is to what extent the intervention reduces the annual leprosy new case detection rate (NCDR) in adults and children compared with routine screening and postexposure prophylaxis (PEP) among close contacts (baseline leprosy control activities). Comparisons will be made with (1) the preintervention NCDR separably among adults and children in South Tarawa (before-after study) and (2) the corresponding NCDRs in the rest of the country. Additionally, the postintervention prevalence of leprosy obtained from a survey of a 'hot-spot' sub-population will be compared with prevalence documented during the intervention. The intervention will be implemented in collaboration with the Kiribati National Leprosy Programme.

ETHICS AND DISSEMINATION

Approval has been obtained from the Kiribati Ministry of Health and Medical Services (MHMS), the University of Otago (H22/111) and the University of Sydney (2021/127) Human Research Ethics Committees. Findings will be shared with the MHMS, local communities and internationally through publication.

Regional comparison on ciguatoxicity, hemolytic activity, and toxin profile of the dinoflagellate Gambierdiscus from Kiribati and Malaysia

The dinoflagellates Gambierdiscus and Fukuyoa can produce Ciguatoxins (CTXs) and Maitotoxins (MTXs) that lead to ciguatera poisoning (CP). The CP hotspots, however, do not directly relate to the occurrence of the ciguatoxic Gambierdiscus and Fukuyoa. Species-wide investigations often showed no association between CTX level and the molecular identity of the dinoflagellates. In the Pacific region, Kiribati is known as a CP hotspot, while Malaysia has only three CP outbreaks reported thus far. Although ciguatoxic strains of Gambierdiscus were isolated from both Kiribati and Malaysia, no solid evidence on the contribution of ciguatoxic strains to the incidence of CP outbreak was recorded. The present study aims to investigate the regional differences in CP risks through region-specific toxicological assessment of Gambierdiscus and Fukuyoa. A total of 19 strains of Gambierdiscus and a strain of Fukuyoa were analyzed by cytotoxicity assay of the neuro-2a cell line, hemolytic assay of fish erythrocytes, and high-resolution mass spectrometry. Gambierdiscus from both Kiribati and Malaysia showed detectable ciguatoxicity; however, the Kiribati strains were more hemolytic. Putative 44-methylgambierone was identified as part of the contributors to the hemolytic activity, and other unknown hydrophilic toxins produced can be potentially linked to higher CP incidence in Kiribati.

"We are the ones who will have to make the change": Cuban health cooperation and the integration of Cuban medical graduates into practice in the Pacific

BACKGROUND

This paper responds to Asante et al. (in Hum Resour Health, 2014), providing an updated picture of the impacts of Cuban medical training in the Pacific region based on research carried out in 2019-2021, which focused on the experiences of Pacific Island doctors trained in Cuba and their integration into practice in their home countries.

METHODS

The research focussed on two case studies-Solomon Islands and Kiribati. Study methods for this research included multi-sited ethnographic methods and semi-structured interviews as well as qualitative analysis of policy documents, reports, and media sources.

RESULTS

The Cuban health assistance programme has had a significant impact on the medical workforce in the Pacific region increasing the number of doctors employed by Pacific Ministries of Health between 2012 and 2019. Qualitatively, there have been some notable improvements in the medical workforce and health delivery over this period. However, the integration of the Cuban-trained doctors into practise has been challenging, with criticisms of their clinical, procedural and communication skills, and the need for the rapid development of bridging and internship training programmes (ITPs) which were inadequately planned for at the outset of the programme.

CONCLUSIONS

The Cuban programme in the Pacific is an important model of development assistance for health in the region. While Cuba's offer of scholarships was the trigger for a range of positive outcomes, the success of the programme has relied on input from a range of actors including support from other governments and institutions, and much hard work by the graduates themselves, often in the face of considerable criticism. Key impacts of the programme to date include the raw increase in the number of doctors and the development of the ITPs and career pathways for the graduates, although this has also led to the reorientation of Cuban graduates from preventative to curative health. There is considerable potential for these graduates to contribute to improved health outcomes across the region, particularly if their primary and preventative health care skills are utilised.

Cancer Disparities among Pacific Islanders: A Review of Sociocultural Determinants of Health in the Micronesian Region

It is well appreciated that the social determinants of health are intimately related with health outcomes. However, there is a paucity of literature that explores these themes comprehensively for the indigenous people within Micronesia. Certain Micronesia-specific factors, such as transitions from traditional diets, the consumption of betel nut, and exposure to radiation from the nuclear bomb testing in the Marshall Islands, have predisposed certain Micronesian populations to an increased risk of developing a variety of malignancies. Furthermore, severe weather events and rising sea levels attributed to climate change threaten to compromise cancer care resources and displace entire Micronesian populations. The consequences of these risks are expected to increase the strain on the already challenged, disjointed, and burdened healthcare infrastructure in Micronesia, likely leading to more expenses in off-island referrals. A general shortage of Pacific Islander physicians within the workforce reduces the number of patients that can be seen, as well as the quality of culturally competent care that is delivered. In this narrative review, we comprehensively underscore the health disparities and cancer inequities faced by the underserved communities within Micronesia.

Metabolic disease in the Pacific: Lessons for indigenous populations

Twenty-five percent of the New Zealand population is either Māori or Pacific and are thus indigenous to the region. The New Zealand National Metabolic Service has considerable experience in diagnosing and managing metabolic diseases in this population. The frequencies and phenotypes of inborn errors of metabolism in indigenous people differ from that in Western European populations. Metabolic services need to be aware of these local variations and adapt their screening and treatment protocols accordingly. Likewise, the services themselves need to adopt culturally appropriate practices. This includes an understanding of the language, ideally employment of indigenous people and targeting of the service to meet the needs of the people. Knowledge of the metabolic diseases common within particular ethnic groups is important for the rapid delivery of appropriate management. Newborn screening protocols need to reflect the local populations. With the advent of expanded newborn screening relatively benign forms of fatty acid oxidation disorders have been commonly encountered. This high prevalence may reflect a selective evolutionary advantage as similar conditions have been found in other ethnic groups with traditionally high fat and low carbohydrate diets. HLA haplotypes of indigenous populations are less represented in international stem cell transplant databanks thereby making the option of human stem cell transplant more challenging. The recent discovery that short-chain enoyl-CoA hydratase deficiency is particularly common in New Zealand with nearly a dozen cases identified this year suggests there is still a lot to learn regarding Māori and Pacific and indeed an indigenous metabolic disease.

My Deep Sea, My Backyard: a pilot study to build capacity for global deep-ocean exploration and research

The deep ocean is the largest ecosystem on the planet, constituting greater than 90% of all habitable space. Over three-quarters of countries globally have deep ocean within their Exclusive Economic Zones. While maintaining deep-ocean function is key to ensuring planetary health, deficiencies in knowledge and governance, as well as inequitable global capacity, challenge our ability to safeguard the resilience of this vast realm, leaving the fate of the deep ocean in the hands of a few. Historically, deep-ocean scientific exploration and research have been the purview of a limited number of nations, resulting in most of humankind not knowing the deep ocean within their national jurisdiction or beyond. In this article, we highlight the inequities and need for increased deep-ocean knowledge generation, and discuss experiences in piloting an innovative project ‘My Deep Sea, My Backyard’ toward this goal. Recognizing that many deep-ocean endeavours take place in countries without deep-ocean access, this project aimed to reduce dependency on external expertise and promote local efforts in two small island developing states, Trinidad and Tobago and Kiribati, to explore their deep-sea backyards using comparatively low-cost technology while building lasting in-country capacity. We share lessons learned so future efforts can bring us closer to achieving this goal.

This article is part of the theme issue ‘Nurturing resilient marine ecosystems’.

Prevalence and Factors Associated With Men's Perpetration of Intimate Partner Violence in South Tarawa, Kiribati

In the Republic of Kiribati, two-thirds of women report experiencing intimate partner violence (IPV) during their lifetime. Less is known about men's perpetration of IPV, or associated risk factors, in this high-prevalence setting. We conducted a cross-sectional study with 429 currently partnered men aged 15 to 49 in South Tarawa, Kiribati, to estimate the prevalence of, and risk factors associated with, currently married men's perpetration of physical and sexual IPV against female partners. Two-thirds (63%) of currently partnered men reported past year physical and/or sexual IPV. Modifiable risk factors associated with men's perpetration of physical and/or sexual IPV included child physical abuse (adjusted odds ratio [aOR]: 2.31, P = .01), gender inequitable attitudes (aOR: 1.12, P = .02), and antisocial behaviors, including gang involvement (aOR: 3.36, P = .01) and involvement in fights with weapons (aOR: 3.54, P = .004). Intimate partner violence prevention approaches in Kiribati should prioritize efforts to prevent child maltreatment, promote gender equitable norms and practices, and reduce community violence.

Prevalence and correlates of suicidal behavior among a national population-based sample of adults in Kiribati

INTRODUCTION

Suicidal behavior is an underresearched cause of death in the Western Pacific region. The study aimed to investigate the prevalence and associated factors of suicidal behavior in a population-based survey among 18-69 year-old persons in Kiribati.

METHOD

Cross-sectional nationally representative data of 2156 18-69 year old persons (37 years were the median age) from the "2015-16 Kiribati STEPS survey" were analyzed.

RESULTS

The results indicate that 5.1% of participants had ever attempted suicide and 9.5% engaged in past 12-month suicidal behavior (ideation, planning, and/or attempts). In adjusted logistic regression analysis, cohabiting, psychological distress, and having had a heart attack, angina, or stroke were associated with lifetime suicide attempts. Female sex, younger age, lower education, psychological distress, heart attack, angina or stroke, and high physical activity were positively associated with past 12-month suicidal behavior. In addition, in unadjusted analysis, alcohol family problems, alcohol dependence, family members attempted suicide, and sedentary behavior (3 to <6 hours/day) were associated with lifetime suicide attempts and/or past 12-month suicidal behavior.

CONCLUSION

Almost one in 10 participants were engaged in suicidal behavior in the past 12 months and several factors were detected which could be targeted in intervention activities.

Zoonotic Soil-Transmitted Helminths in Free-Roaming Dogs, Kiribati

Soil-transmitted helminths are highly prevalent in the Asia-Pacific region. We report a 96.5% prevalence of zoonotic soil-transmitted helminths in dogs in Kiribati. We advocate for urgent implementation of treatment and prevention programs for these zoonotic pathogens, in line with the Kiribati-World Health Organization Cooperation Strategy 2018-2022.

SARS-CoV-2 Wave Two Surveillance in East Asia and the Pacific: Longitudinal Trend Analysis

Background

The COVID-19 pandemic has had a profound global impact on governments, health care systems, economies, and populations around the world. Within the East Asia and Pacific region, some countries have mitigated the spread of the novel coronavirus effectively and largely avoided severe negative consequences, while others still struggle with containment. As the second wave reaches East Asia and the Pacific, it becomes more evident that additional SARS-CoV-2 surveillance is needed to track recent shifts, rates of increase, and persistence associated with the pandemic.

Objective

The goal of this study is to provide advanced surveillance metrics for COVID-19 transmission that account for speed, acceleration, jerk, persistence, and weekly shifts, to better understand country risk for explosive growth and those countries who are managing the pandemic successfully. Existing surveillance coupled with our dynamic metrics of transmission will inform health policy to control the COVID-19 pandemic until an effective vaccine is developed. We provide novel indicators to measure disease transmission.

Methods

Using a longitudinal trend analysis study design, we extracted 330 days of COVID-19 data from public health registries. We used an empirical difference equation to measure the daily number of cases in East Asia and the Pacific as a function of the prior number of cases, the level of testing, and weekly shift variables based on a dynamic panel model that was estimated using the generalized method of moments approach by implementing the Arellano-Bond estimator in R.

Results

The standard surveillance metrics for Indonesia, the Philippines, and Myanmar were concerning as they had the largest new caseloads at 4301, 2588, and 1387, respectively. When looking at the acceleration of new COVID-19 infections, we found that French Polynesia, Malaysia, and the Philippines had rates at 3.17, 0.22, and 0.06 per 100,000. These three countries also ranked highest in terms of jerk at 15.45, 0.10, and 0.04, respectively.

Conclusions

Two of the most populous countries in East Asia and the Pacific, Indonesia and the Philippines, have alarming surveillance metrics. These two countries rank highest in new infections in the region. The highest rates of speed, acceleration, and positive upwards jerk belong to French Polynesia, Malaysia, and the Philippines, and may result in explosive growth. While all countries in East Asia and the Pacific need to be cautious about reopening their countries since outbreaks are likely to occur in the second wave of COVID-19, the country of greatest concern is the Philippines. Based on standard and enhanced surveillance, the Philippines has not gained control of the COVID-19 epidemic, which is particularly troubling because the country ranks 4th in population in the region. Without extreme and rigid social distancing, quarantines, hygiene, and masking to reverse trends, the Philippines will remain on the global top 5 list of worst COVID-19 outbreaks resulting in high morbidity and mortality. The second wave will only exacerbate existing conditions and increase COVID-19 transmissions.

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

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

Patient Perspectives of Diabetes and Diabetic Retinopathy Services in Kiribati: A Qualitative Study

Diabetes mellitus is an increasing global health problem affecting millions of people worldwide, especially true in the Republic of Kiribati, with >20% of adults suffering from type 2 diabetes, and the prevalence is rising. Information on I-Kiribati patients' understanding of diabetes and perception of access to relevant services is sparse. This study explores patient perspectives on their condition and its management using Talanga and Kakala Pacific research methodologies. Data were collected from Kiribati patients in four focus group interviews. Key themes to emerge were knowledge about diabetes, understanding and accessing the health care system, making lifestyle changes, and suggestions for improvement. Health system failures to meet the complex health care needs of these patients and health care services gaps are apparent. Improvements suggested include a comprehensive village-based health promotion and community development program focusing on youth and schools from early childhood and onward, increase in the skilled workforce, and an integrated approach to service delivery.

The Differential Influence of Geographic Isolation on Environmental Migration: A Study of Internal Migration Amidst Degrading Conditions in the Central Pacific

This study investigates how geographic isolation interacts with declining environmental and economic conditions in Kiribati, an island nation wherein which limited access to financial resources amidst degrading environmental conditions potentially constrain capital-intensive, long distance migration. We examine whether geographic isolation modifies the tenets of two dominant environmental migration theses. The environmental scarcity thesis suggests that environmental degradation prompts migration by urging households to reallocate labor to new environments. In contrast, the environmental capital thesis asserts that declining natural resource availability restricts capital necessary for migration. Results show that the commonly applied environmental scarcity thesis is less valid and the environmental capital thesis is more relevant in geographically isolated places. Findings indicate that geographic isolation is an important dimension along which migration differences emerge. As overall environmental and economic conditions worsen, likelihoods of out-migration from less remote islands increase whereas likelihoods of out-migration from more isolated islands decrease.

Obesity measures in the Kiribati population: a need to reclassify body mass index cut-points

BACKGROUND

Obesity is a public health problem in Micronesia. The objective of the study was to assess obesity, the relationship between body mass index (BMI) and body fat percentage (BF%) among adults, and determine the appropriate BMI cut-points in Kiribati.

METHODS

A cross-sectional study was undertaken among 483 adults randomly selected from South Tarawa (ST) and Butaritari (BT). Weight, height, BF% and physical activity level (PAL) was measured using standard methods. Linear and quadratic regression analyses were conducted to assess the association between BF% and BMI whilst controlling for age and gender. Receiver operating characteristics (ROC) curve analyses were used to assess whether for the Kiribati population alternative BMI cut-off points for obesity are needed.

RESULTS

Approximately 75% of participants were obese using standard BMI and BF% cut-offs, with the highest prevalence observed in South Tarawa. BF% was significantly (p < 0.001) and positively associated with age (males, r = 0.78; females, r = 0.67; p < 0.001) and BMI. Based on ROC-curve analyses the BMI cut-offs for predicting high BF% among I-Kiribati people were 24.5 kg/m2 for males and 32.9 kg/m2 for females.

CONCLUSIONS

In conclusion, the majority of adults in Kiribati were either obese or overweight and had high BF%. We suggest that ethnic-specific BMI cut-points to define obesity for the population of Kiribati may be more appropriate than the currently used international cut-points.

Hepatitis B and D in the Pacific Islands of Kiribati

BACKGROUND

Historical reports indicate that hepatitis B and hepatitis D are highly endemic in the Pacific Island of Kiribati but current levels are unknown.

OBJECTIVES

To determine current prevalence of HBV and HDV in Kiribati, characterize the strains in both mono-infection and co-infection and assess individuals for antiviral therapy.

STUDY DESIGN

Sera obtained from 219 patients were screened for HBsAg, HBeAg, HBV DNA, anti-HD, and HDV RNA. 61 HBV isolates were sequenced for genotype, phylogenetic analysis and detection of pre-core and basal core promoter mutations. 82 HDV isolates were also sequenced.

RESULTS

55.7 % HBsAg positive samples had antibodies to HDV and 73.2 % had detectable HDV RNA, indicating that 40.8 % HBsAg-positive individuals had current HBV/HDV co-infection. There were 42 co-infected males and 40 females; the youngest individual was a 4 year-old boy. HBV isolates were genotype D4, and HDV strains formed a distinct Pacific clade of genotype 1. Undetectable HBV DNA loads were statistically more frequent in the co-infected sub-population (p < 0.0001). Basal core promoter and pre-core mutations were present in both mono and co-infection.

CONCLUSION

Kiribati has one of the highest HBV/HDV co-infection rates in the world. The epidemiology of co-infection in this population was unusual with males and females equally represented and the presence of co-infection in a 4 year old child suggesting neonatal or early horizontal transmission, which is extremely rare. Coinfection with HDV resulted in statistically significant suppression of HBV DNA levels. The HDV strain identified in Kiribati was unique to the Pacific Islands.

Surveillance of Leprosy in Kiribati, 1935-2017

In Kiribati, unlike most countries, high and increasing numbers of cases of leprosy have been reported despite the availability of multidrug therapy and efforts to improve case finding and management. Historic records show that 28 cases had been identified by 1925. A systematic population survey in 1997 identified 135 new cases; the mean incidence rate for 1993–1997 was 7.4/10,000 population. After administering mass chemoprophylaxis, the country reached the elimination threshold (prevalence <1/10,000), but case numbers have rebounded. The mean annualized rate of new cases in 2013–2017 was 15/10,000 population, with the highest new case rates (>20/10,000 population) in the main population centers of South Tarawa and Betio. Spread is expected to continue in areas where crowding and poor socioeconomic conditions persist and may accelerate as sea levels rise from climate change. New initiatives to improve social conditions are needed, and efforts such as postexposure chemoprophylaxis should be implemented to prevent spread.

Cirripectes matatakaro, a new species of combtooth blenny from the Central Pacific, illuminates the origins of the Hawaiian fish fauna

Included among the currently recognized 23 species of combtooth blennies of the genus Cirripectes (Blenniiformes: Blenniidae) of the Indo-Pacific are the Hawaiian endemic C. vanderbilti, and the widespread C. variolosus. During the course of a phylogeographic study of these species, a third species was detected, herein described as C. matatakaro. The new species is distinguished primarily by the configuration of the pore structures posterior to the lateral centers of the transverse row of nuchal cirri in addition to 12 meristic characters and nine morphometric characters documented across 72 specimens and ∼4.2% divergence in mtDNA cytochrome oxidase subunit I. The new species is currently known only from the Marquesas, Gambier, Pitcairns, Tuamotus, and Australs in the South Pacific, and the Northern Line Islands and possibly Johnston Atoll south of Hawaiʻi. Previous researchers speculated that the geographically widespread C. variolosus was included in an unresolved trichotomy with the Hawaiian endemic and other species based on a morphological phylogeny. Our molecular-phylogenetic analysis resolves many of the previously unresolved relationships within the genus and reveals C. matatakaro as the sister lineage to the Hawaiian C. vanderbilti. The restricted geographic distribution of Cirripectes matatakaro combines with its status as sister to C. vanderbilti to indicate a southern pathway of colonization into Hawaiʻi.

Temporal decline in diarrhea episodes and mortality in Kiribati children two years following rotavirus vaccine introduction, despite high malnutrition rates: a retrospective review

Background

Kiribati introduced rotavirus vaccine in 2015. To estimate the impact of rotavirus vaccine on acute gastroenteritis (AGE) and severe acute malnutrition (SAM) among children under 5 in Kiribati, a retrospective review of inpatient and outpatient AGE and hospitalized SAM was undertaken.

Methods

Inpatient data for admissions and hospital deaths due to AGE, SAM and all-causes were collected for children under 5 from all hospitals on the main island, Tarawa, from January 2010–December 2013 (pre-rotavirus vaccine) and January 2016–September 2017 (post-rotavirus vaccine). National outpatient diarrhea data were collected from January 2010 to August 2017 for under 5. An interrupted time-series analysis was undertaken to estimate the effect of rotavirus vaccine on the rates of inpatient and outpatient AGE, inpatient SAM; and inpatient case fatality rates for AGE and SAM, were calculated pre- and post-rotavirus vaccine introduction.

Results

The incidence rate of AGE admissions from Tarawa and national AGE outpatient presentations significantly declined by 37 and 44%, respectively, 2 years following rotavirus vaccine introduction. There was a significant decline in the percentage of AGE contributing to all-cause under 5 admissions (12·8% vs. 7·2%, p < 0·001) and all-cause under-five mortality (15·9% vs. 5·7%, p = 0·006) pre- and post-rotavirus vaccine introduction. The estimated incidence rate of inpatient SAM decreased by 24% in under 5 s, 2 years following rotavirus vaccine introduction.

Conclusions

AGE morbidity and mortality and hospitalized SAM rates have declined following rotavirus vaccine introduction in Kiribati children.

Are Households in Kiribati Nutrition Secure? A Case Study of South Tarawa and Butaritari

BACKGROUND AND OBJECTIVES

This study assessed the nutritional status among householders in urban South Tarawa and rural Butaritari in Kiribati.

METHODS AND STUDY DESIGN

In this cross-sectional study, we assessed energy and nutrient intakes, food variety scores, and dietary diversity scores of men and women from 468 households randomly selected in South Tarawa (n = 161) and Butaritari (n = 307) using a 24-hour dietary recall. Nutrient adequacy ratios and mean adequacy ratios of selected nutrients were also determined from 3-day weighed food records collected among participants living in a further 28 households from South Tarawa (n = 29) and Butaritari (n = 44).

RESULTS

Based on the 24-hour dietary recall, the average energy intake for men and women was 2536 kcals and 2068 kcals, respectively. Carbohydrate (CHO), fat, and protein intakes for men and women were 332.5 g, 76.5 g, and 130.4 g and 291.7 g, 55.1 g, and 103.5 g, respectively. The mean and standard deviation of household Food Variety Score and Dietary Diversity Score was 3.90 ± 1.25 and 5.44 ± 1.92, respectively. Intakes of vitamin A, calcium, and iron, and zinc were notably deficient in both locations, with the urban participants having lower intakes of vitamin B-1, vitamin B-2, magnesium, and potassium than their rural counterparts. Mean sodium intakes exceeded recommendations for all age groups in South Tarawa except children aged 4 to 6 years.

CONCLUSIONS

Food consumption patterns of the households in South Tarawa and Butaritari reflected high consumption of nontraditional diets and refined foods, which manifested in inadequate micronutrient intake estimates and low dietary diversity: strong risk factors for noncommunicable diseases such as obesity and diabetes.

Ocular Chlamydia trachomatis infection, anti-Pgp3 antibodies and conjunctival scarring in Vanuatu and Tarawa, Kiribati before antibiotic treatment for trachoma

•

In Vanuatu, ocular Chlamydia infection prevalence is low; in Kiribati it is high.

•

In Vanuatu, Pgp3 seroprevalence does not increase in childhood; in Kiribati it does.

•

Conjunctival scarring is more common in adults in Kiribati than in Vanuatu.

•

Trachomatous inflammation—follicular lacks specificity for ocular Chlamydia infection.

•

Non-TF markers may help to determine need for interventions against active trachoma.

Introduction

In the peri-elimination setting, the positive predictive value of trachomatous inflammation–follicular (TF), the primary marker used to determine need for antibiotics for trachoma, is suboptimal. Here, three non-TF measures are used to compare two regions where TF prevalence exceeds the threshold for intervention, but where the Chlamydia trachomatis (Ct) prevalence is different.

Methods

Population prevalence of trachoma was measured in Vanuatu (n = 3470) and Kiribati (n = 2922). Dried blood spots (DBS) and conjunctival photographs were collected from every survey participant, and conjunctival swabs were collected from those aged 1–9 years. Individuals were tested for blood anti-Pgp3 antibodies, Ct DNA at the conjunctiva and severity of conjunctival scarring.

Results

The prevalence of TF in 1–9-year-olds was 16.5% in Vanuatu and 38.2% in Tarawa. 7% of people aged ≥1 year in Vanuatu had conjunctival scarring compared to 27% in Tarawa. The prevalence of ocular Ct infection in 1–9-year-olds was 1.5% in Vanuatu and 27.4% in Tarawa. The seroconversion rate amongst 1–9-year-old children in Vanuatu and Tarawa was 0.018 and 0.197 events per child per year, respectively.

Conclusions

Comparing Vanuatu to Tarawa demonstrates several markers that could be used to differentiate the trachoma status of populations in these (and other) locations.

Lifestyle behaviour and prevalence of cardiovascular risk factors - a pilot study comparing Kiribati and European seafarers

Background

According to internal observations within a German shipping company, obvious risk-behaviour persists among the crew members coming from the Pacific Island State of Kiribati and representing a large part of the crew aboard merchant vessels of this company. These observations were related to excessive eating habits. This study aims to assess the cardiovascular risk among seafarers and to compare lifestyle factors between Kiribati and European crew members.

Methods

In the present maritime field study 81 sailors (48 Kiribati, 33 European, average age at 38.9 and 36.8 years respectively) were examined from April until August 2014 aboard four container ships crossing the Atlantic Ocean (participation rate of 90.9%).

Results

Based on the number of established risk factors, 35.4% of the Kiribati and 16.7% of the European crew members were regarded as a high risk group for cardiovascular diseases. The HDL-values of Kiribati were found to be considerably lower (34.9 mg/dl) than the references values given by the WHO and in comparison to the European crew members (44.8 mg/dl) (p = 0.002). 91.7% of Kiribati and 51.5% of European participants were found to be overweight according to WHO-criteria - with a mean Body Mass Index (BMI) of 30.3 kg/m² and 25.6 kg/m² (p <  0.001). Regarding lifestyle factors Kiribati often claimed to eat significantly larger amounts of food aboard while most European sailors stated to eat less or about the same during their shipboard stay (p = 0.017). Daily sleeping hours were slight on both sides; however with a mean of 5.2 h a day Kiribati crew members had significant fewer sleep (p = 0.038). The examined Kiribati sailors had a mean increase in weight of 6 kg over a 12 months period of observation.

Conclusions

In total the compiled data points towards a higher risk of cardiovascular diseases particularly due to alimentary habits within the Kiribati crew members. The distinct weight-gain measured among the Kiribati in spite of higher energy consumption levels at sea is alarming. Thus, the results of this study confirm the necessity of health-improving interventions aboard cargo vessels.

Climate change, food security and health in Kiribati: a narrative review of the literature

Background: Climate change is recognised as having a ‘multiplier effect’ on food insecurity and adverse health experiences of communities in the Pacific region. Islands are especially at risk due to their limited land availability, population pressures and, in the case of atolls, their low-lying topography making them vulnerable to sea level rise.

Aim: This review examines the literature describing the relationship between climate change, food security and health in Kiribati.

Method: A narrative review was conducted, looking at both peer-reviewed and non-peer-reviewed literature available online from 1 January 2008 to 14 August 2018, the search date. Sources from three databases of peer-reviewed literature, Google and additional sources from reference lists were included in the review.

Results: Thirty-seven items were included in this review. These show climate change is having a noticeable impact on food security and health in Kiribati. Four themes were identified from the literature that provide different perspectives to the problem outlined.

Conclusion: Climate change is a pressing concern for the government of Kiribati and communities alike, and yet the problem is worsening, not improving. Further research is required to look at effective policies and cultural perspectives to address this problem.

A qualitative exploration of behavioral factors affecting mothers of malnourished children under 5 years old in Kiribati

Background: In Kiribati, malnutrition is the leading cause of death for children aged less than 5 years. The purpose of this study was to explore contributing behavioral factors among mothers of malnourished children under 5 years old in Kiribati.

Methods: This qualitative study was conducted in an urban area of South Tarawa among mothers of malnourished children aged less than 5 years in 11 public health centers in 2016. The study included 9 focus group discussions, with a sub sample of 3 to 4 in each group, having a total of 35 participants. Using a semi-structured questionnaire, data was collected and thematic analysis was applied to analysis the data. 

Results: Seven main themes were identified including; knowledge, behaviors, perceived severity, perceived benefits to action, perceived barriers and cultural related issues. These encompassed a variety of reasons which could explain the malnutrition in children of those particular mothers.

Conclusion: In order to tackle malnutrition in Kiribati, it is crucial to identify the main factors that are hindering this preventable disease. This study provides information essential to enhanced decision making, health care delivery planning and has policy implications for the improvement of quality of health care in Kiribati.

Emergency care in Kiribati: A combined medical and nursing model for development

OBJECTIVES

To summarise recent developments in emergency care in Kiribati, a developing Pacific Island nation. Multiple donor countries and agencies have partnered in this process. Changes in medical training, staffing models and planned infrastructure developments are all described, with a particular focus on a recent emergency nurse training programme.

METHODS

A bespoke nurse education course was developed by external clinical nurse specialists in collaboration with local administrators and clinicians, incorporating WHO Basic Emergency Care course. The nine-day course was delivered to 18 nurses, over a 3-week period to accommodate rostering requirements. Pre- and post-course assessment was undertaken.

RESULTS

Quantitative assessment improved from 87.11 ± 7.46 (mean ± SD) to 94.89 ± 5.95 (t = 5.45, P < 0.001). Qualitative scenario-based assessment confirmed marked improvement.

CONCLUSIONS

A multifaceted development strategy has proven essential for progression in emergency care. Nurse education is an essential component of this, and the existing model has potential for other similar nations.

Food offerings on board and dietary intake of European and Kiribati seafarers - cross-sectional data from the seafarer nutrition study

Background

Overweight and cardiovascular risk factors are a common phenomenon in seafarers. According to internal observation particularly crew members from the Pacific Island State of Kiribati are exposed to a high risk. However, in mixed crews, cultural background plays an important role, influencing food choice, and the actual risk.

Methods

The Seafarer Nutrition Study (SeaNut study) compared dietary factors in 48 Kiribati and 33 European male seafarers recruited from four merchant ships with a high level of Kiribati manning within a German shipping company. Analysis encompassed the assessment of dietary quality on board, satisfaction with prepared dishes, and individual food intake obtained from 24-h recalls in comparison with nutritional recommendations.

Results

The overall supply of meat, fat and eggs was more than double, whereas the proportions of fruits, vegetables, dairy products and cereals were much lower than recommended. Based on the reported food choices, both groups, but notably Kiribati seafarers, did not reach reference values as to macronutrient, micronutrient and fiber intake. In addition, satisfaction with the meals served, food preferences and knowledge about a healthy diet varied markedly between Kiribati and Europeans.

Conclusions

The present analysis of the SeaNut study revealed the necessity of future health intervention programs, including the quality of the food supply as well as information about a healthy diet and adequate food selection. In mixed crews, culture-specific differences should be considered, in order to facilitate the long-term success of interventions.

Trial registration

German Clinical Trials Registry DRKS00010819 retrospectively. Registered 18 July 2016 (www.germanctr.de).

Impact of Laboratory Practice Changes on the Diagnosis of Tuberculosis with the Introduction of Xpert MTB/RIF in Kiribati

The Republic of Kiribati, Central Pacific, has the largest tuberculosis epidemic in the region. There is a national tuberculosis control program, which has used smear microscopy for acid-fast bacilli as the main diagnostic tool for many years. In 2015, an Xpert MTB/RIF machine was procured and became functional within the tuberculosis hospital. The aim of this cross-sectional study, using routinely collected data, was to determine the effects of introducing Xpert MTB/RIF on laboratory smear microscopy practices and the pattern of registered tuberculosis cases. Between February 2015 and January 2016, there were 220 Xpert MTB/RIF assays performed with 6.4% errors and 15% detection of Mycobacterium tuberculosis: one patient showed rifampicin-resistance. One year before and after introducing Xpert MTB/RIF, the number of presumptive tuberculosis patients increased by 9% from 2,138 to 2,322. There were no changes in demographic characteristics, smear-positive results, or acid-fast bacilli grade between the two periods. The number of specimens cultured for Mycobacterium tuberculosis significantly declined from 638 to zero, with 76 positive MTB cultures before and none after introducing Xpert MTB/RIF. There was a significant change in the profile of registered tuberculosis cases with more children (34% versus 21%) and fewer bacteriologically-confirmed cases (29% versus 43%) - P < .001. Since the deployment of Xpert MTB/RIF in Kiribati, there have been a small number of assays performed and this has been associated with no adverse effects on smear microscopy, a stoppage in mycobacterial cultures, and a change in the types and categories of diagnosed tuberculosis.

Taxonomic assignment of the benthic toxigenic dinoflagellate Gambierdiscus sp. type 6 as Gambierdiscus balechii (Dinophyceae), including its distribution and ciguatoxicity

Recent molecular phylogenetic studies of Gambierdiscus species flagged several new species and genotypes, thus leading to revitalizing its systematics. The inter-relationships of clades revealed by the primary sequence information of nuclear ribosomal genes (rDNA), however, can sometimes be equivocal, and therefore, in this study, the taxonomic status of a ribotype, Gambierdiscus sp. type 6, was evaluated using specimens collected from the original locality, Marakei Island, Republic of Kiribati; and specimens found in Rawa Island, Peninsular Malaysia, were further used for comparison. Morphologically, the ribotype cells resembled G. scabrosus, G. belizeanus, G. balechii, G. cheloniae and G. lapillus in thecal ornamentation, where the thecal surfaces are reticulate-foveated, but differed from G. scabrosus by its hatchet-shaped Plate 2', and G. belizeanus by the asymmetrical Plate 3'. To identify the phylogenetic relationship of this ribotype, a large dataset of the large subunit (LSU) and small subunit (SSU) rDNAs were compiled, and performed comprehensive analyses, using Bayesian-inference, maximum-parsimony, and maximum-likelihood, for the latter two incorporating the sequence-structure information of the SSU rDNA. Both the LSU and SSU rDNA phylogenetic trees displayed an identical topology and supported the hypothesis that the relationship between Gambierdiscus sp. type 6 and G. balechii was monophyletic. As a result, the taxonomic status of Gambierdiscus sp. type 6 was revised, and assigned as Gambierdiscus balechii. Toxicity analysis using neuroblastoma N2A assay confirmed that the Central Pacific strains were toxic, ranging from 1.1 to 19.9 fg P-CTX-1 eq cell^-1, but no toxicity was detected in a Western Pacific strain. This suggested that the species might be one of the species contributing to the high incidence rate of ciguatera fish poisoning in Marakei Island.

Should Kiribati continue to aim for 100% voluntary non-remunerated blood donation as recommended by the WHO?

Setting: Tungaru Central Hospital Blood Bank Laboratory, Nawerewere, Tarawa, Kiribati. Objective: To determine characteristics, deferrals and reasons for deferral amongst blood donors from 2011 to 2016. Design: A cross-sectional study using routinely collected data. Results: From January 2011 to March 2016, 8531 potential blood donors were registered. For each full year, the proportion of voluntary non-remunerated blood donors (VNRBD) was below 10%, although it increased to 13% in 2015. The overall proportion of blood donors deferred increased each year over the 5-year period, from 44% to 57%, with similar increases in deferrals in VNRBD and family replacement donors (FRD). Among all blood donors, a higher proportion of females than males (59% vs. 43%) and VNRBD than FRD (56% vs. 44%) were deferred (P < 0.001). Deferrals were due to 1) failing the medical questionnaire (53%), 2) having anaemia and/or high white cell count (26%), or 3) transfusion-transmissible infections (21%). More VNRBD were deferred due to failing the medical questionnaire, while more FRD were deferred due to anaemia and/or high white-cell count; the number of deferrals was similar for transfusion-transmissible infections. Conclusion: This 5-year study showed that the proportion of VNRBD is low and deferrals are higher for this group than for FRD. There is a strong case for encouraging both types of donor in the country.

Progress towards achieving hepatitis B control in the Cook Islands, Niue, Tokelau, and Kiribati

BACKGROUND

Hepatitis B virus (HBV) is highly endemic in many of the Pacific Island countries. Four island countries-Cook Islands, Kiribati, Niue, and Tokelau-sought to evaluate the success of their hepatitis B vaccination programs by conducting nationally representative serosurveys among children born post-vaccine introduction.

METHODS

Cook Islands, Niue, and Tokelau conducted school-based census serosurveys because of small populations. The Cook Islands tested children in second grade; Niue tested children in early childhood education through sixth grade; and Tokelau tested children in first through sixth grades. Because Kiribati has a much larger birth cohort, it conducted a one-stage stratified serosurvey among first grade students. All four countries tested children using the Alere Determine™ rapid point of care hepatitis B surface antigen (HBsAg) test.

RESULTS

In the three smaller countries, no children were seropositive for HBsAg (0/245 Cook Island students, 0/183 Niuean students, 0/171 Tokelau students). In Kiribati, 39 (3.3%, 95% confidence interval 2.4-4.6%) of 1249 students were HBsAg positive. Vaccination data collected in the Cook Islands and Tokelau showed high vaccination coverage in both countries with ⩾95% birth dose coverage and 100% 3-dose coverage.

CONCLUSIONS

The Cook Islands, Niue, and Tokelau have made remarkable progress in establishing strong vaccination programs and towards decreasing the burden of hepatitis B among children. Kiribati still needs to improve vaccination coverage to achieve the <1% HBsAg target established by the World Health Organization Western Pacific Region.

Mortality and life expectancy in Kiribati based on analysis of reported deaths

BACKGROUND

Kiribati is an atoll country of 103,058 (2010 Census) situated in the central Pacific. Previous mortality estimates have been derived from demographic analyses of census data. This is the first mortality analysis based on reported deaths.

METHODS

Recorded deaths were from the Ministry of Health and the Civil Registration Office for 2000-2009; populations were from the 2000, 2005, and 2010 censuses. Duplicate death records were removed by matching deaths within and between data sources using a combination of names, date of death, age, sex, island of residence, and cause of death. Probability of dying <5 years (5q0) and 15-59 years (45q15), and life expectancy (LE) at birth, were computed with 95 % confidence intervals. These data were compared with previous census analyses.

RESULTS

There were 8,681 unique deaths reported over the decade 2000-2009 in Kiribati. The reconciled mortality data indicate 5q0 for both sexes of 64 per 1,000 live births in 2000-2004, and 51 for 2005-2009 (assuming no under-enumeration), compared with 69 and 59 for comparable periods from the 2005 and 2010 census analyses (children ever-born/children surviving method). Based on reconciled deaths, LE at birth (e0) for males was 54 years for 2000-2004 and 55 years in 2005-2009, five years lower than the 2005 and 2010 census estimates for comparable periods of 59 and 58 years. Female LE was 62 years for 2000-2004 and 63 years for 2005-2009, two-three years less than estimates for comparable periods of 63 and 66 years from the 2005 and 2010 census analyses. Adult mortality (45q15) was 47-48 % in males and 27-28 % in females from reconciled mortality over 2000-2009, higher than census estimates of 34-38 % in males and 21-26 % in females for the same periods. The reconciled data are very likely to be incomplete and actual mortality higher and life expectancy lower than reported here.

CONCLUSION

This analysis indicates higher mortality than indirect demographic methods from the 2005 and 2010 Censuses. Reported deaths are most likely under-reported; especially 5q0, as many early neonatal deaths are probably classified as stillbirths. These analyses suggest that the health situation in Kiribati is more serious and urgent than previously appreciated.

Early Substance Use Initiation and Suicide Ideation and Attempts among School-Aged Adolescents in Four Pacific Island Countries in Oceania

This study aimed to investigate the correlations between early initiation (<12 years) of smoking cigarettes, alcohol use, and drug use (cannabis) with suicidal ideation and suicide attempts in school-aged adolescents in four Pacific Island countries in Oceania. The sample included 6540 adolescents (≤13 to ≥16 years old) from Kiribati, Samoa, Solomon Islands, and Vanuatu. Bivariate and multivariable analyses were conducted to assess the association between pre-adolescent substance use initiation and suicidal ideation and suicide attempts. Results indicate a prevalence of 25.8% suicidal ideation in the past 12 months (ranging from 17.2% in Vanuatu to 34.7% in Kiribati) and 34.9% suicide attempts in the past 12 months (ranging from 23.5% in Vanuatu to 62.0% in Samoa). The prevalence of early cigarette smoking initiation was 15.7%, early alcohol initiation 13.8%, and early drug use initiation was 12.9%. Students who reported pre-adolescent substance use initiation, compared with non-substance users, were more likely reporting suicidal ideation and suicide attempts. The concurrent initiation of cigarette smoking, alcohol, and drug use should be targeted in early prevention programmes in order to prevent possible subsequent suicidal behaviours.

Battling tuberculosis in an island context with a high burden of communicable and non-communicable diseases: epidemiology, progress, and lessons learned in Kiribati, 2000 to 2012

OBJECTIVES

To examine the epidemiology of tuberculosis (TB) in Kiribati from 2000 to 2012, document lessons learned, and recommend ways to mitigate the burden of TB in Kiribati.

METHODS

A descriptive study was performed using data on TB case notifications, prevalence, incidence, mortality, and treatment outcomes from global reports and data files. Progress towards meeting the Millennium Development Goal TB target (to reduce TB incidence by 2015) and the Regional Strategy to Stop Tuberculosis in the Western Pacific 2011-2015 targets (to reduce TB prevalence and mortality by half by 2015 relative to the level in 2000) was examined.

RESULTS

TB case notifications and the estimated incidence and prevalence have increased in Kiribati since 2000. From 2000 to 2012, Kiribati reported a total of 3863 TB notifications; in 2012, the case notification rate was 343/100 000 population. The majority (89%) of TB patients complete treatment and/or are cured, and the estimated TB mortality rate has remained relatively stable at around 16/100 000 population. HIV testing of TB patients has increased over recent years from 8% of notifications tested in 2003 to 43% tested in 2012. Of all 818 tests, only four (0.5%) patients were confirmed HIV-positive. Drug-resistant TB has been detected in a small number of cases.

CONCLUSIONS

TB rates continue to increase in Kiribati and the 2015 goals for TB control are unlikely to be met. This is probably due to the complex mix of risk factors present in Kiribati, including smoking, diabetes, alcohol use, crowded living, and poverty. A comprehensive approach to address these risk factors is needed to mitigate the burden of TB in Kiribati.

Establishment, management, and maintenance of the phoenix islands protected area

The Republic of Kiribati's Phoenix Islands Protected Area (PIPA), located in the equatorial central Pacific, is the largest and deepest UNESCO World Heritage site on earth. Created in 2008, it was the first Marine Protected Area (MPA) of its kind (at the time of inception, the largest in the world) and includes eight low-lying islands, shallow coral reefs, submerged shallow and deep seamounts and extensive open-ocean and ocean floor habitat. Due to their isolation, the shallow reef habitats have been protected de facto from severe exploitation, though the surrounding waters have been continually fished for large pelagics and whales over many decades. PIPA was created under a partnership between the Government of Kiribati and the international non-governmental organizations-Conservation International and the New England Aquarium. PIPA has a unique conservation strategy as the first marine MPA to use a conservation contract mechanism with a corresponding Conservation Trust established to be both a sustainable financing mechanism and a check-and-balance to the oversight and maintenance of the MPA. As PIPA moves forward with its management objectives, it is well positioned to be a global model for large MPA design and implementation in similar contexts. The islands and shallow reefs have already shown benefits from protection, though the pending full closure of PIPA (and assessments thereof) will be critical for determining success of the MPA as a refuge for open-ocean pelagic and deep-sea marine life. As global ocean resources are continually being extracted to support a growing global population, PIPA's closure is both timely and of global significance.

AIDS education reaches Pacific atolls

The Republic of Kiribati consists of 33 islands and 69,000 inhabitants dispersed over a large area of the Central Pacific. It includes the former Gilbert Islands, which were linked as British colonies with the Ellice Islands until the latter declared themselves independent as Tuvalu. Kiribati became independent from Britain in 1979 and joined WHO [the World Health Organization] in 1984. Launched in 1988, the national AIDS program is now implementing its second medium-term plan. As part of this plan, the program recently held its first AIDS awareness workshop for hotel workers, health care workers and youth. The workshop was held on Kiritimati, the world's largest atoll. Also known as Christmas Island, the atoll of 2650 inhabitants has excellent bird-watching and fishing opportunities, which have drawn growing numbers of tourists in recent years. Although neither of the two HIV infections identified in Kiribati by March 1994 were on Kiritimati, the prevalence of other sexually transmitted diseases there has been on the rise. Meeting in a traditional thatched building, the workshop participants proved eager to learn about HIV and STDs [sexually transmitted diseases]. They received instruction in prevention skills, including a demonstration of proper condom use led by the national AIDS coordinator. At the close of the workshop, condoms were provided to hotel staff for distribution.

Risk factors for xerophthalmia in the Republic of Kiribati

OBJECTIVES

To identify risk factors for xerophthalmia in the Republic of Kiribati.

DESIGN

Case-control study.

SETTING

The Republic of Kiribati.

SUBJECTS

666 xerophthalmic preschool children (cases) and 816 children without xerophthalmia (controls) from a population-based sample of 4619 children who participated in a xerophthalmia prevalence survey.

MAIN OUTCOME MEASURES

Clinical signs of xerophthalmia (night blindness, Bitot's spots, corneal xerophthalmia and keratomalacia).

RESULTS

Multivariable logistic regression models showed older age [1.35(1.24, 1.47)] [odds ratio (95% confidence interval)]; male sex [1.32(1.05, 1.67)]; recent diarrhea [1.45(1.10, 1.89)]; severe [3.82(2.73, 5.35)], moderate [3.55(2.04, 6.18)], and mild [3.07(2.33, 4.04)] protein-energy malnutrition; current breast-feeding [0.30(0.19, 0.46)]; higher frequency of consumption of carotenoid-containing fruits and vegetables [0.93(0.80, 0.96)]; and the presence of a Foundation for the Peoples of the South Pacific garden project [0.70(0.52, 0.93)] were each independently associated with xerophthalmia. A recent history of measles was associated with corneal xerophthalmia [7.73(1.78, 33.65)].

CONCLUSIONS

These data provide further evidence of the relationship between xerophthalmia and factors that may be amenable to intervention, and suggest that greater availability and consumption of provitamin A carotenoids is associated with decreased risk of xerophthalmia among preschool children.

The demography of Kiribati: estimates from the 1985 census

"This paper presents an analysis of the 1985 census [of Kiribati] and compares projections made on the basis of that analysis with the 1990 enumeration. Comparison is made throughout with the estimates derived from [the] 1978 census." Information is provided on population growth and structure, child and adult mortality, marriage and first birth, and fertility.

Age and infertility in a micronesian atoll population

The relationship between female age and infertility is examined using a single-island Micronesian population case. Demographic data, derived primarily from reproductive history interviews, show that a significant age-associated decline in marital reproductive performance is absent before women reach their late thirties in this population but a substantial decline is present once women reach their forties. Ethnographic data support the demographic inference that couples are maintaining relatively high levels of conjugal coital activity with both advancing female age and increasing marital duration. Thus coital activity levels appear to be an important factor in the maintenance of fertility in this group before the mid-thirties but decreases in fecundability after this age are due primarily to reductions in fecundity, not to declines in coital activity. The description of the Butaritari case lends support to Underwood's (1990) suggestion that a "Micronesian pattern" of reproductive performance may exist for the region's atoll-based populations and underscores the promise of further investigations of these special cases in the fields of demography and reproductive ecology.

Differential mortality of Asians and Pacific Islanders in the Pacific labour trade

"Quantitative evidence is presented on the differential mortality suffered by Indian and Pacific Island labour migrants on Fiji's plantations between 1883 and 1919, and by Japanese, Chinese and Pacific Island labour migrants in the phosphate mines on Ocean Island and Nauru between 1913 and 1940. Pacific Island labour migrants suffered much higher death rates than Asian labour migrants, due, it is suggested, to their much greater vulnerability to newly introduced infectious diseases."

Population redistribution policies and development planning in the Pacific Basin: rationale and objectives

"In this article, the general arguments about population redistribution are discussed within the context of [Pacific island nations]....A review of circular and permanent population movements in the Pacific Basin reveals the complexity of the networks of relations of multilocal people....A range of possible population policies to accomodate and correct migration problems is discussed. An analysis of the national development plans of Fiji, Kiribati, and the Solomon Islands illustrates the need for sustainable development and population redistribution policies which explicitly address: (a) nation-building with regional equity; (b) population growth control and native supremacy; and (c) population redistribution with ecological sustainability." Comments are included by A. Crosbie Walsh (pp. 102-6) and Antony J. Dolman (pp. 107-11).

HTLV-1, HIV-1, hepatitis B and hepatitis delta in the Pacific and South-East Asia: a serological survey

Blood samples from 13 locations in the Pacific and South-East Asia were tested for evidence of infection with human T-cell lymphotropic virus type-1 (HTLV-1), human immunodeficiency virus (HIV-1), hepatitis B virus (HBV) and hepatitis delta virus (HDV). No samples were positive for antibody to HIV-1. Antibodies to HTLV-1 were found in samples from five locations, the maximum prevalence being 19%, in Vanuatu. Serological markers of HBV infection were found in all locations, the maximal prevalence being 88%, in Majuro, Micronesia. Antibodies to HDV in HBsAg positive sera were found in six locations with a maximum prevalence of 81% in Kiribati.

Venereal diseases in the islands of the North Pacific

Apart from the Japanese islands, and those of Karabati (lately Gilbert Islands), which lie just north of the equator, the islands of the northern Pacific Ocean are either American owned or otherwise administered. Even the Japanese islands were controlled by the USA for varying numbers of years after the second world war. Venereal disease statistics from Guam, the Trust Territory of the Pacific Islands, and the Gilbert Islands have been collated by the South Pacific Commission and will be presented in a second paper. Those from the Hawaiian Islands (the fiftieth state of the USA) are published by the United States Public Health Service and include those from Honolulu, the capital. While the rates per 100 000 for both syphilis and gonorrhoea are lower than those for the USA as a whole, the trends since 1970 have been less satisfactory in the state of Hawaii than for the whole of the United States. While the disturbing increasing incidence of primary and secondary syphilis was checked in 1977, that of gonorrhoea has continued to rise. The number of cases of gonorrhoea also increased in Guam and the Trust Territory of the Pacific Islands but there has been a recent fall from earlier peak figures. The pattern of venereal disease in the most developed Pacific islands is thus gradually approaching what may be expected elsewhere in modern western society and it would seem logical to expect that this trend will continue.