An assessment of non-communicable diseases, diabetes, and related risk factors in the Republic of Palau: a systems perspective.

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the Republic of Palau and describes the burden due to selected NCD (diabetes, heart disease, hypertension, stroke, chronic kidney disease); and assesses the system of service capacity and current activities for service delivery, data collection, and reporting as well as identifying the issues that need to be addressed. There has been a 7.1% increase in the population between 2000 and 2010. Significant shifts in the age groups show declines among children and young adults under 34 years of age and increases among adult residents over 45 years of age. Findings reveal that the risk factors of poor diet, lack of physical activity, and lifestyle behaviors are associated with overweight and obesity and subsequent NCD that play a significant role in the morbidity and mortality of the population. The leading causes of death include heart disease and cancer. A 2003 community household survey was conducted and 22.4% of them reported a history of diabetes in the household. A survey among Ministry of Health employees showed that 44% of the men and 47% of the women were overweight and 46% of the men and 42% of the women were obese. Other findings show significant gaps in the system of administrative, clinical, and support services to address these NCD. Priority issues and needs for the administrative and clinical systems were identified.

Copy number variants for schizophrenia and related psychotic disorders in Oceanic Palau: risk and transmission in extended pedigrees.

BACKGROUND: We report on copy number variants (CNVs) found in Palauan subjects ascertained for schizophrenia and related psychotic disorders in extended pedigrees in Palau. We compare CNVs found in this Oceanic population with those seen in other samples, typically of European ancestry. Assessing CNVs in Palauan extended pedigrees yields insight into the evolution of risk CNVs, such as how they arise, are transmitted, and are lost from populations by stochastic or selective processes, none of which are easily measured from case-control samples. METHODS: DNA samples from 197 subjects affected with schizophrenia and related psychotic disorders, 185 of their relatives, and 159 control subjects were successfully characterized for CNVs using Affymetrix Genomewide Human SNP Array 5.0. RESULTS: Copy number variants thought to be associated with risk for schizophrenia and related disorders also occur in affected individuals in Palau, specifically 15q11.2 and 1q21.1 deletions, partial duplication of IL1RAPL1 (Xp21.3), and chromosome X duplications (Klinefelter's syndrome). Partial duplication within A2BP1 appears to convey an eightfold increased risk in male subjects (95% confidence interval, .8-84.4) but not female subjects (odds ratio = .4, 95% confidence interval, .03-4.9). Affected-only linkage analysis using this variant yields a logarithm of the odds score of 3.5. CONCLUSIONS: This study reveals CNVs that confer risk to schizophrenia and related psychotic disorders in Palau, most of which have been previously observed in samples of European ancestry. Only a few of these CNVs show evidence that they have existed for many generations, consistent with risk variants diminishing reproductive success.

High prevalence of an anti-hypertriglyceridemic variant of the MLXIPL gene in Central Asia.

MLXIPL is a transcription factor integral to the regulation of glycolysis and lipogenesis in the liver. Common variants of the MLXIPL gene (MLXIPL) are known to influence plasma triglyceride levels in people of European descent. As MLXIPL has a key role in energy storage, genetic variations of the MLXIPL may be relevant to physiological adaptations to nutritional stresses that have occurred during the evolution of modern humans. In the present study, we assessed the phenotypic consequences of the Q241H variant of MLXIPL in populations of Asian and Oceanian origin and also surveyed the prevalence of Q241H variant in populations worldwide. Multiple linear regression models based on 2373 individuals of Asian origin showed that the H allele was significantly associated with decreased concentrations of plasma triglycerides (P=0.0003). Direct genotyping of 1455 individuals from Africa, Asia and Oceania showed that the triglyceride-lowering H allele was found at quite low frequencies (0.00-0.16) in most of the populations examined. The exceptions were some Central Asian populations, including Mongolians, Tibetans and Uyghurs, which exhibited much higher frequencies of the H allele (0.21-0.26). The high prevalence of the H allele in Central Asia implies that the Q241H variant of MLXIPL might have been significant for utilization of carbohydrates and fats in the common ancestors of these populations, who successfully adapted to the environment of Central Asia by relying on nomadic livestock herding.

Chronic disease surveillance systems within the US Associated Pacific Island jurisdictions.

In recent years, illness and death due to chronic disease in the US Associated Pacific Islands (USAPI) jurisdictions have dramatically increased. Effective chronic disease surveillance can help monitor disease trends, evaluate public policy, prioritize resource allocation, and guide program planning, evaluation, and research. Although chronic disease surveillance is being conducted in the USAPI, no recently published capacity assessments for chronic disease surveillance are available. The objective of this study was to assess the quality of existing USAPI chronic disease data sources and identify jurisdictional capacity for chronic disease surveillance. The assessment included a chronic disease data source inventory, literature review, and review of surveillance documentation available from the web or through individual jurisdictions. We used the World Health Organization's Health Metric Network Framework to assess data source quality and to identify jurisdictional capacity. Results showed that USAPI data sources are generally aligned with widely accepted chronic disease surveillance indicators and use standardized data collection methodology to measure chronic disease behavioral risks, preventive practices, illness, and death. However, all jurisdictions need to strengthen chronic disease surveillance through continued assessment and expanded support for valid and reliable data collection, analysis and reporting, dissemination, and integration among population-based and institution-based data sources. For sustained improvement, we recommend investment and technical assistance in support of a chronic disease surveillance system that integrates population-based and institution-based data sources. An integrated strategy that bridges and links USAPI data sources can support evidence-based policy and population health interventions.

Early signs and symptoms of psychosis among Palauan adolescents.

AIM: This study was designed to identify early symptoms associated with the occurrence of psychosis during adolescence. METHOD: Participants were recruited in the Republic of Palau, an isolated island nation in Micronesia with a prevalence rate for schizophrenia of 1.99%. Diagnostic interviews were used to obtain reports of early and current symptoms from 112 genetically high-risk (GHR) and 208 genetically low-risk (GLR) adolescents (ages 16-23). Based on current psychotic symptoms, participants were sorted into three groups: non-clinical, at-risk/symptomatic risk and clinically symptomatic. RESULTS: Multivariate analysis of variance revealed several between-group differences on rates of early symptoms. Most notably, youth who were in the GHR-clinically symptomatic group reported significantly higher rates of early marijuana use than GLR-clinically symptomatic youth, who were significantly more likely to report early symptoms of depression and behaviour disorders. In addition, several gender based differences in the link between early symptoms and adolescent onset psychosis were noted. CONCLUSIONS: Findings are generally consistent with previous research on early indicators, though several unexpected findings suggest that results from this study may not be fully generalizable beyond this relatively isolated and culturally distinct Micronesian nation.

Adoption, family relations and psychotic symptoms among Palauan adolescents who are genetically at risk for developing schizophrenia.

PURPOSE: This paper focuses on the role of adoption and family relations as moderators of genetic risk for psychotic disorders. METHODS: Participants included 184 adolescents in the Republic of Palau identified to be at genetic risk for schizophrenia and other psychotic disorders. Palau is an island nation in Micronesia with a lifetime prevalence of 1.99% for schizophrenia and 2.67% for psychotic disorders more broadly defined. In Palauan culture, kinship adoption is a common cultural practice; 47 of the 184 participants had been adopted at an early age. The current study was designed to test the hypothesis that adoption would function as a protective factor among Palauan youth at genetic risk for the development of psychotic symptoms. Participants were evaluated for psychotic and other psychiatric symptoms using KSADS-PL. Concurrently, the Youth Self Report was used to assess the perceived quality of family relationships. RESULTS: Results indicated that adopted adolescents were more likely to develop psychotic symptoms than non-adopted adolescents. However, perceived family relations moderated the association between adoption status and psychotic symptoms, such that adopted adolescents with poorer family relations reported disproportionately higher rates of psychotic symptoms. Family relations also moderated the association between level of genetic risk and psychotic symptoms, independently of adoption status. CONCLUSION: Consistent with previous research, adolescents at high genetic risk who reported more positive family relations also reported fewer psychotic symptoms.

Diversity in genes responsible for lifestyle-related diseases in Asia-Pacific region.

In Asia-Pacific countries, both environmental modernization and hereditary traits of Mongoloid reported to cause rapid increase in lifestyle-related diseases (LRD). However, reproducibility of reported responsive-factors is low. To examine this, a decision-tree method of complexity-model was applied to select LRD-responsive-factors. Genomic DNA was collected from Asia-Pacific regions. Single nucleotide polymorphisms (SNPs) on genomic DNA were determined as hereditary-trait-factor. Three indices of LRD (BMI, body fat, and serum leptin levels) were classified according to published criteria. WEKA Machine-learning system was used as decision-tree software. Age was added as a factor with different dimension. Selected factors were validated by other statistical methods. In Thai-males, GLUT) (glucose-transporter 1)-SNP was most-responsive to body fat, followed by USF1-SNP (transcription-factor for lipid metabolism). Differences between genotypes were validated (P = .002 for GLUT1 by Levene's, P = .071 for USF1 by ANOVA). Responsive-factors of Thai-females, Palau-males and Palau-females, were consisted with SNPs and age, and varied by groups. Convincing responsive-factors were not selected from mixed-data. Decision-tree-analysis successfully selected the convincing results. Responsive-factors differed by ethnic group and gender.

Palau 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 health care 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 Palau assessment. Meant to establish a baseline for future reference, all data were collected in 2004-2005 and have not been updated.

Endemic hepatitis B virus infection and chronic liver disease mortality in the Republic of Palau, 1990-2002.

In the Republic of Palau, a Pacific island nation, approximately 20% of the population is chronically infected with hepatitis B virus (HBV) and is at risk of developing chronic liver disease (CLD), including cirrhosis and hepatocellular carcinoma (HCC). To examine the consequences of HBV infection, we sought to quantify HBV-related CLD mortality in this population. The cause of death was abstracted from death certificates of all persons who died in Palau during 1990-2002. CLD deaths were categorised as cirrhosis or HCC. HBV serological status was determined by review of a hospital database. The cause of death was determined for 1,366 (85%) of 1,608 deaths. CLD was the fifth most common cause of death, accounting for 102 (7%) deaths with a known cause. Of deaths due to CLD, 55 (54%) were from cirrhosis and 47 (46%) were from HCC. Sixty-five percent of CLD decedents and 19% of non-CLD decedents were chronically infected with HBV (P<0.01). The attributable fraction of HBV-related CLD was 54% (58% for cirrhosis and 53% for HCC). CLD mortality rates were approximately twice the worldwide CLD rate. HBV-related CLD is a common cause of death in the Republic of Palau, highlighting the importance of routine infant hepatitis B vaccination, especially in countries with high endemicity.

Scrub typhus, Republic of 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.

Managing health care system in small island countries: Palau.

Managing health systems in small island countries carry with it challenges that are common with other small communities around the world but also articulates for unique challenges that are intrinsically that of small island countries. Sustainability of economies and the small population in small island countries in the Pacific dictates how health care services align and organize to meet the needs of their population. This paper is an attempt to outline possible strategies that could be implemented in view of the ever decreasing meager resources. It will outline a step approach toward realignment and reengineering a viable health care system that is hopefully both cost effective and outcome oriented.

The Pacific Center for Emergency Health--an anatomy of collaborative development and change--the Palau perspective.

Many Pacific Islands Countries (PICs) by their geographic location, isolation, and lack of resources, are at risk for both environmental and man-made disasters. Disaster management (DM) and mitigation is frustrated by the general underdevelopment of DM planning and lack of adequate emergency medical services (EMS) to deal with daily emergencies let alone large-scale emergencies and disasters. To address this, the U.S. Centers for Disease Control and Prevention (CDC) developed and implemented the Pacific Emergency Health Initiative (PEHI) to review and make recommendations regarding the current level of DM/EMS development of select PICs. As a practical next step, a collaborative demonstration project--the CDC--Palau Community College Pacific Center for Emergency Health--was established in the Republic of Palau with the purpose of providing training and technical assistance in DM/EMS development for the region. In September 2001 the Center conducted two simultaneous training programs addressing Public Health Disaster Planning (one-week) and pre-hospital First Responder Care (two-weeks). Sixty participants included public health planners, physicians, and fire and police officials from eleven PIC jurisdictions and representatives from the Secretariat of the Pacific Community, South Pacific Applied Geoscience Commission, and the Fiji School of Medicine. Eleven country and state public health disaster plans were initiated. Post 9-11 the Center has increased relevance. Through CDC's PEHI additional Center training programs are planned through FY 2003.

Incest in Palau: "Delemumuu undressed".

Black (1978) and Shewman (1992) have written specifically about incest in the Palauan society however, these publications in some respect have fallen short of articulating the essence of incest as a subject of severe conflict in the traditional and contemporary Palauan society. This paper will attempt to lay out the cultural framework from which incest is defined, summarize actual cases of incest in Palau and finally discuss some future actions needed to clarify the definition as well as, detailing the "burden" of incest in the Palauan society. Information review reveals that incest is occurring in Palau in alarming rate however, most of the information are communicated through kelulau (whispers). Kelulau is a secretive and subliminal way for the Palauans to discuss some of these extremely mekull subjects especially, incest. It is the level of kebliil where incest is defined and could differ from clan to clan. Through kelulau one begins to understand that in the Palauan society incest is defined vertically and horizontally through the different units of the social structures. Kelulau reports higher rates of incest even before 1992. Current data bank does provide enough information for accurate prevalence rate incest in Palau to be determined. The article has attempted to provide some basic information about incest in Palau. In all of these incest is defined vertically and horizontally. The Palauan society must be held as the overall perpetrator if, it continues to neglect addressing the issue of incest in Palau.

Human resource development in environmental health for Palau--a model program for Micronesia and the Pacific.

In Palau, prior to 1997, the highest degree qualification in Sanitation Division (now called Division of Environmental Health) under the Bureau of Public Health, Ministry of Health, was a Diploma in Environmental Health from the Fiji School of Medicine. By September 2003, during an Environmental Health Planning and Management Workshop (NEHAP), Human Resource Development (HRD) was declared as a priority area and therefore was incorporated into the Palau National Environmental Health Action Plan. The Palau NEHAP HRD goal is to develop a human resource development plan for environmental health, which builds a career ladder with incentives. The initial public health courses in environmental health commenced in August 2004. A total of 25 participants registered for the sentinel course--PH 122: Introduction to Environmental Health. Students represented Palau's varied environmental health workforce, which included representatives from the National Division of Environmental Health and state sanitation programs. In December 2004 the Diploma of Public Health (DPH) Program in Palau was finalized The environmental health workforce of Palau is very fortunate to be included in the Palau AHEC programs. This have come about due to the ongoing Ministry of Health support of environmental health program in Palau.

Palau's current and future capacity for disaster management.

Despite the challenges of geographic isolation, a small population and limited financial resources, the Republic of Palau has been able to significantly improve its ability to address disasters through establishing an emergency health program funded by US Federal Grants. The ability to prevent and respond to ordinary emergencies and disasters has been bolstered by creating electronic Public Health and Hospital Emergency Operations Plans, improving and creating hospital surge capacity infrastructure in all units beyond recommended minimums, initiating a database of volunteers with disaster response related skills, creating pharmacy caches, developing a national HAZAMT team, teaching critical incident stress debriefing skills, creating and expanding communications networks, improving the pre-hospital care system, conducting active disease surveillance, and improving the scope and quality of lab services. New policies and procedures are implemented and sustained through an active education system incorporating drills, exercises and didactic teaching sessions. These improvements are being made in accordance with local and international legal standards.

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.

Disease surveillance during the VII South Pacific Mini Games, Palau 2005--lessons learnt.

During July/August 2005, Palau hosted the VII South Pacific Mini Games. With an expected influx of at least 2000 athletes and visitors, the Palau Ministry of Health (MOH) decided to operate under an Emergency Incident Command Structure for the duration of the event. Surveillance for infectious diseases and injury was carried out under this framework by the Epidemiology/Intelligence team (Epi Team) established for the event. Health providers traveling with visiting teams or working in Koror were requested to complete daily log sheets of encounters using standardized case definitions. These sheets were collected each evening, either from designated "drop-off" points or directly from the team accommodation, and entered into a Microsoft Access database. Reports were generated and reviewed each morning to provide current statistics for the Incident Command meeting and determine further actions as appropriate. 912 games related encounters were recorded. 19.5% (178) of these presentations were at MOH operated facilities or field teams. The remaining 80.5% presented to visiting medical delegations. 689 (75.5%) of the presentations were considered to be "initial" visits, with the remainder recorded as follow-up visits. Of these "initial" visits the most common diagnoses were injury, prevention (massage or strapping), upper respiratory illness, headache, and dehydration. There were no outbreaks of infectious disease detected during the games. Although several issues with the surveillance methodology arose during the games, the event highlighted the importance of good communication and a flexible team approach in carrying out effective surveillance. It is recommended that future events adopt a similar approach, with a strong emphasis given in the planning stages to establishing direct contact between the staff responsible for surveillance and field and visiting health personnel.