Cascade of Care for Alaska Native People With Chronic Hepatitis C Virus Infection: Statewide Program With High Linkage to Care

Most persons with chronic hepatitis C virus (HCV) infection in the United States are undiagnosed or linked to care. We describe a program for the management of Alaska Native patients infection utilizing a computerized registry and statewide liver clinics resulting in higher linkage to care (86%) than national estimates (~25%).

Prevalence of diagnosed diabetes in American Indian and Alaska Native adults, 2006-2017

INTRODUCTION

The objective of this study was to examine recent trends in diagnosed diabetes prevalence for American Indian and Alaska Native (AI/AN) adults aged 18 years and older in the Indian Health Service (IHS) active clinical population.

RESEARCH DESIGN AND METHODS

Data were extracted from the IHS National Data Warehouse for AI/AN adults for each fiscal year from 2006 (n=729 470) through 2017 (n=1 034 814). The prevalence of diagnosed diabetes for each year and the annual percentage change were estimated for adults overall, as well as by sex, age group, and geographic region.

RESULTS

After increasing significantly from 2006 to 2013, diabetes prevalence for AI/AN adults in the IHS active clinical population decreased significantly from 2013 to 2017. Prevalence was 14.4% (95% CI 13.9% to 15.0%) in 2006; 15.4% (95% CI 14.8% to 16.0%) in 2013; and 14.6% (95% CI 14.1% to 15.2%) in 2017. Trends for men and women were similar to the overall population, as were those for all age groups. For all geographic regions, prevalence either decreased significantly or leveled off in recent years.

CONCLUSIONS

Diabetes prevalence in AI/AN adults in the IHS active clinical population has decreased significantly since 2013. While these results cannot be generalized to all AI/AN adults in the USA, this study documents the first known decrease in diabetes prevalence for AI/AN people.

Combating Gastric Cancer in Alaska Native People: An Expert and Community Symposium

Alaska Native (AN) people experience higher incidence of, and mortality from, gastric cancer compared to other U.S. populations1 , 2 . Compared to the general U.S. population, gastric cancer in AN people occurs at a younger age, is diagnosed at later stages, is more evenly distributed between the sexes, and is more frequently signet-ring or diffuse histology3 . It is known that the prevalence of Helicobacter pylori (Hp ) infection, a risk factor for gastric cancer, is high in AN people4 ; however, high antimicrobial resistance combined with high reinfection rates in Alaska make treatment at the population level complex5 . In addition, health issues in AN people are uniquely challenging due to the extremely remote locations of many residents.

A multiagency workgroup hosted a symposium in Anchorage that brought internationally-recognized experts and local leaders together to evaluate issues around gastric cancer in the AN population. The overall goal of this symposium was to identify the best strategies to combat gastric cancer in the AN population through prevention and early diagnosis.

Trends in Cancer Incidence Among American Indians and Alaska Natives and Non-Hispanic Whites in the United States, 1999-2015

BACKGROUND

Female breast, prostate, lung, and colorectal cancers are the leading incident cancers among American Indian and Alaska Native (AI/AN) and non-Hispanic White (NHW) persons in the United States. To understand racial differences, we assessed incidence rates, analyzed trends, and examined geographic variation in incidence by Indian Health Service regions.

METHODS

To assess differences in incidence, we used age-adjusted incidence rates to calculate rate ratios (RRs) and 95% confidence intervals (CIs). Using joinpoint regression, we analyzed incidence trends over time for the four leading cancers from 1999 to 2015.

RESULTS

For all four cancers, overall and age-specific incidence rates were lower among AI/ANs than NHWs. By Indian Health Service regions, incidence rates for lung cancer were higher among AI/ANs than NHWs in Alaska (RR: 1.46; 95% CI: 1.37, 1.56) and Northern (RR: 1.29; 95% CI: 1.25, 1.33) and Southern (RR: 1.06; 95% CI: 1.03, 1.09) Plains. Similarly, colorectal cancer incidence rates were higher in AI/ANs than NHWs in Alaska (RR: 2.29; 95% CI: 2.14, 2.45) and Northern (RR: 1.04; 95% CI: 1.00, 1.09) and Southern (RR: 1.11; 95% CI: 1.07, 1.15) Plains. Also, AI/AN women in Alaska had a higher incidence rate for breast cancer than NHW women (RR: 1.05; 95% CI: 1.05, 1.20). From 1999 to 2015, incidence rates for all four cancers decreased in NHWs, but only rates for prostate (average annual percent change: -4.70) and colorectal (average annual percent change: -1.80) cancers decreased considerably in AI/ANs.

CONCLUSION

Findings from this study highlight the racial and regional differences in cancer incidence.

Prevalence of serum antibodies to Coxiella burnetii in Alaska Native Persons from the Pribilof Islands

BACKGROUND

Q fever is a febrile illness caused by infection with the bacterium Coxiella burnetii. It is most often transmitted by inhalation of the bacteria after it is shed by infected livestock. Recent studies have found very high C. burnetii infection rates among marine mammals, but it is not known if shedding by marine mammals creates a risk of Q fever among humans. To better understand infection of humans with exposure to marine mammals, the prevalence of antibodies against C. burnetii in serum samples taken from Alaskan Native persons residing on the Pribilof Islands was evaluated. The Pribilof Islands support large populations of northern fur seals infected with C. burnetii that may increase the risk of exposure for island residents.

METHODS

Serum testing for IgG antibodies against C. burnetii (phase I and phase II) was performed, and demographic data were analysed utilizing banked serum specimens drawn from island residents from 1980 to 2000.

RESULTS

The overall seroprevalence rate was 11.6% (95% CI = 9.3%-14.4%; 72/621). This is higher than the previously reported 3.1% (95% CI = 2.1%-4.3%) seroprevalence for the U.S.

POPULATION

CONCLUSIONS

These results suggest that Alaskan Native persons may be at higher risk for exposure to C. burnetii than the general US. population, possibly due to proximity to large populations of infected marine mammals.

Association of Food Access, Recreational Opportunities, and Natural Amenities with Engagement in the Veterans MOVE! Weight Management Program

OBJECTIVE

The aim of this study was to examine the association of county-level food access, recreational opportunities, and natural amenities with participant engagement in a weight management program.

METHODS

In this cohort study, participants in the Veterans Health Administration MOVE! weight management program between October 1, 2007, and September 30, 2013, were observed for 12 months after enrollment. Engagement was measured as the number of program visits per year at 12 months. Cross-sectional analysis and spatial regression were used to examine county characteristics associated with greater participant engagement at 12 months.

RESULTS

A total of 321,624 participants in 2,708 counties were included. Greater engagement was associated with older age, female sex, white race, being married, and being retired. After accounting for similarities between nearby communities, engagement at 12 months was 3.1 visits higher for each additional farmers' market per 1,000 population (P = 0.01). Engagement was highest for participants living in counties with the most natural amenities (P < 0.001). Recreational opportunities had only a small effect on engagement in the program (β = 0.02 visits at 12 months; P = 0.002).

CONCLUSIONS

Consideration of a participant's county characteristics in addition to other known demographics and program factors may help to explain variation in engagement in weight management programs.

Agreement between self-reported and central cancer registry-recorded prevalence of cancer in the Alaska EARTH study

Reliance on self-reported health status information as a measure of population health can be challenging due to errors associated with participant recall. We sought to determine agreement between self-reported and registry-recorded site-specific cancer diagnoses in a cohort of Alaska Native people. We linked cancer history information from the Alaska Education and Research Towards Health (EARTH) cohort and the Alaska Native Tumor Registry (ANTR), and calculated validity measures (sensitivity, specificity, positive predictive value, negative predictive value, kappa). Multiple logistic regression models were used to assess independent associations of demographic variables with incorrect reporting. We found that among Alaska EARTH participants, 140 self-reported a history of cancer, and 99 matched the ANTR. Sensitivity ranged from 79% (colorectal cancer) to 100% (prostate cancer); specificity was over 98% for all-sites examined. Kappa was higher among prostate and female breast cancers (κ=0.86) than colorectal cancers (κ=0.63). Women (odds ratio [OR] (95% confidence interval [CI]): 2.8 (1.49-5.31)) and participants who were older than 50 years (OR (95% CI): 2.8 (1.53-4.12)) were more likely to report incorrectly. These data showed good agreement between self-reported and registry-recorded cancer history. This may be attributed to the high quality of care within the Alaska Tribal Health System, which strongly values patient-provider relationships and the provision of culturally appropriate care.

Disparities in social determinants of health outcomes and behaviours between older adults in Alaska and the contiguous US: evidence from a national survey

Few studies have focused on understanding how sociodemographic factors impact healthy ageing in the rapidly growing population of Alaskan older adults. Therefore, the objectives of this study are to compare the health of Alaskan older adults to those in the contiguous US, and determine how the associations differ between older adults in Alaska and the contiguous US. We abstracted 165,295 respondents age 65+ from the 2016 Behavioral Risk Factor Surveillance System. We used generalised linear models to assess the associations between sociodemographic factors and six health outcomes accounting for confounders and complex sampling. In the contiguous US, females were less likely than males to be obese (OR 0.96, 95%CI 0.96-0.97), while in Alaska, females were more likely to be obese (OR 1.24, 95%CI 1.19-1.29). In the contiguous US, Alaska Natives/American Indians were more likely than respondents of other races to be smokers (OR 1.62, 95%CI 1.60-1.63), while in Alaska, the association between race and smoking was not significant (OR 1.00, 95%CI 0.94-1.06). These differences between Alaska and the contiguous US results suggest that programs designed to reduce disparities and promote healthy behaviours may need to be tailored to meet the unique needs and challenges of older adults living in Alaska.

Invasive breast cancer among Alaska Native women in Alaska

Female breast cancer is the most common cancer diagnosed among Alaska Native (AN) women. We examined characteristics of and trends for female breast cancer among AN women. We assessed descriptive statistics, incidence trends (1969-2014), and cause-specific survival for female breast cancers recorded in the Alaska Native Tumor Registry. Results indicated that the majority of breast cancers among AN were diagnosed among women aged over 50 years, at local stage, and with Hormone receptor (HR)+/Human Epidermal Growth Factor (HER) 2- subtype. Five-year average incidence (95% CI) in the most recent time-period (2009-2014) was 145.0/100,000 (130.4, 159.5)); this was not statistically different from the previous time-period. Survival from breast cancer was high and varied by stage and cancer subtype. Hazard of death was greater among those diagnosed with regional/distant/unknown disease, relative to local disease (HR (95%CI): 4.65 (1.66, 12.98)), and higher among those with HER2-/HR- cancers, relative to those with HER2-/HR+ cancers (HR (95%CI): 6.59 (2.23, 19.49)). This study provides a comprehensive description of breast cancer among AN women, providing new and updated information on clinical and demographic factors, cancer incidence trends, regional variations and breast cancer survival. Abbreviations: AIAN: American Indian/Alaska Native; AN: Alaska Native; ANMC: Alaska Native Medical Center; ANTR: Alaska Native Tumor Registry; CI: Confidence Interval; HR: Hazard Ratio; ICD-O-3: International Classification of Diseases for Oncology - Third Edition; NHW - Non-Hispanic Whites; SEER: Surveillance, Epidemiology and End Results.

Risk Factors for Group A Streptococcus Colonization During an Outbreak Among People Experiencing Homelessness in Anchorage, Alaska, 2017

We identified risk factors for any emm type group A streptococcal (GAS) colonization while investigating an invasive emm26.3 GAS outbreak among people experiencing homelessness in Alaska. Risk factors included upper extremity skin breakdown, sleeping outdoors, sharing blankets, and infrequent tooth brushing. Our results may help guide control efforts in future outbreaks.

High Prevalence of Adenomatous Polyps in Alaska Native People Aged 40-49 years

BACKGROUND

Although colorectal cancer occurs earlier in life and at twice the frequency in Alaska Native (AN) people compared with the general population, the colorectal polyp burden in this group has not been quantified. In addition, an appropriate age for initial screening in ANs has not been defined.

MATERIALS AND METHODS

A retrospective chart review of 766 AN people who had screening colonoscopy from 2015 to 2016 was performed. The polyp burden in patients aged 40-49 y was compared with that in those aged 50-59 y in both the AN and the general US populations.

RESULTS

In total, 345 adenomas were removed: 121 (35%) from 40- to 49-year-olds and 224 (65%) from 50- to 59-year-olds. Twenty-six percent of AN people aged 40 y to 49 y and 40% of AN people aged 50 to 59 y had at least one adenoma. Low- and high-risk adenomas were significantly less frequent in the younger group (22% versus 29%, P = 0.048; 9.2% versus 15%, P = 0.035; respectively). Advanced adenomas were also less frequent in the younger group, although not statistically significant. Polyp histology, size, location, and morphology did not differ significantly between groups.

CONCLUSIONS

The adenoma and advanced adenoma prevalence in 40- to 49-year-old AN people is high, suggesting colorectal cancer screening should begin at age 40 y in ANs.

Use of sexual health services among American Indian and Alaska Native Women

Because use of sexual health services among American Indian/Alaska Native women is understudied we: (1) examined disparities in use of sexual health services between American Indian/Alaska Native and non-Hispanic white women and (2) identified factors associated with service use among American Indian/Alaska Native women. We used data from the National Survey of Family Growth regarding the use of sexual health services collected between 2006 and 2010 from women aged 15-44 years who self-identified as American Indian/Alaska Native (n = 819) and white (n = 6,196). Weighted logistic regression models estimated the likelihood of reporting the use of sexual health services by race and factors associated with use in the American Indian/Alaska Native sample. Compared to whites, American Indian/Alaska Native women were less likely to use birth control services and more likely to use services for sexually transmitted diseases and HIV. Among American Indian/Alaska Natives, younger women were more likely to use birth control services, and women who had a higher number of sexual partners were more likely to use services for sexually transmitted diseases and HIV. Our results provide a national baseline against which to assess disparities and changes in the use of sexual health services among American Indian/Alaska Native women over time.

Follow-up Study Methods for a Longitudinal Cohort of Alaska Native and American Indian People Living within Urban South Central Alaska: The EARTH Study

Longitudinal data are needed to investigate chronic disease causation and improve prevention efforts for Alaska Native and American Indian (ANAI) people. This paper describes the methods used to conduct follow-up data collection of a longitudinal cohort that enrolled ANAI adults between 2004 and 2006 in south central Alaska. The follow-up study re-examined ANAI participants in a large, urban centre in south central Alaska between 2015 and 2017. Computerized surveys were used to collect self-reported health, lifestyle, physical activity, and diet data. Clinical measurements included blood pressure, fasting blood glucose and lipid panel, urine albumin/creatinine, height, weight, and waist and hip circumference. Participants were provided individual results at the conclusion of their visit. A total of 1320 south central Alaska study participants completed the baseline visit. Study staff attempted to contact all living cohort members for inclusion in the follow-up study. More than 11,000 attempted contacts were made. Of the 637 available for participation, 388 completed the follow-up visit. The proportion of women increased from baseline to follow-up examinations (67 vs. 72%, p < 0.01). Self-reported health status of being married or living as married (46% vs. 39%, p < 0.01), and those reporting being employed or self-employed (55% vs. 47%, p < 0.01) were higher at follow-up when compared to baseline. Almost all participants at follow-up (97%) agreed to long-term storage of biological specimens for future study. Despite demographic differences between the follow-up and baseline cohorts, longitudinal data collected will provide novel insight on chronic disease development and prevention for ANAI people as well as other populations.

A Prospective Study of the Development of Inflammatory Arthritis in the Family Members of Indigenous North American People With Rheumatoid Arthritis

OBJECTIVE

To determine the incidence of inflammatory arthritis and autoantibody prevalence in Indigenous North American people.

METHODS

Unaffected relatives of Indigenous North Americans with rheumatoid arthritis (RA) from central Canada and Alaska were systematically monitored from 2005 to 2017. Rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPAs) were tested at every visit, and a subset was tested for ACPA fine specificity using a custom multiplex assay. Multistate models based on all available study visits were developed to determine the likelihood of transitioning between autoantibody states, or to inflammatory arthritis.

RESULTS

Eighteen of 374 relatives (4.8%) developed inflammatory arthritis during follow-up (after a mean ± SD of 4.7 ± 2.4 years), yielding a transition rate of 9.2 cases/1,000 person-years. Thirty percent of those who developed inflammatory arthritis were seronegative at baseline, but all were seropositive at inflammatory arthritis onset. Although 30% of ACPA/RF double-seropositive individuals developed inflammatory arthritis (after 3.2 ± 2.2 years), the majority of these individuals did not develop inflammatory arthritis. Multistate modeling indicated a 71% and 68% likelihood of ACPA and RF seropositive states, respectively, reverting to a seronegative state after 5 years, and a 39% likelihood of an ACPA/RF double-seropositive state becoming seronegative. Fine specificity testing demonstrated an expansion of the ACPA repertoire prior to the development of inflammatory arthritis.

CONCLUSION

Despite a high incidence of inflammatory arthritis in this cohort of at-risk relatives of Indigenous North Americans with RA, a large proportion of autoantibody-positive individuals do not develop inflammatory arthritis and revert back to an autoantibody-negative state.

With a Spirit that Understands: Reflections on a Long-term Community Science Initiative to End Suicide in Alaska

This retrospective analysis of a long-term community-based participatory research (CBPR) process spans over two decades of work with Alaska Native communities. A call to action from Alaska Native leadership to create more effective strategies to prevent and treat youth suicide and alcohol misuse risk initiated a response from university researchers. This CBPR process transformed into a collaborative effort to indigenously drive and develop solutions through research. The People Awakening project started our team on this translational and transformational pathway through community intervention science in the Central Yup'ik region of Alaska. We examine more deeply the major episodes and their successes and struggles in maintaining a long-term research relationship between university researchers and members of Yup'ik Alaska Native communities. We explore ways that our CBPR relationship has involved negotiation and engagement with power and praxis, to deepen and focus attention to knowledge systems and relational elements. This paper examines these deeper, transformative elements of our CBPR relationship that spans histories, cultures, and systems. Our discussion shares vignettes from academic and community perspectives to describe process in a unique collaboration, reaching to sometimes touch upon rare ground in emotions, tensions, and triumphs over the course of a dozen grants and twice as many years. We conclude by noting how there are points where, in a long-term CBPR relationship, transition out of emergence into coalescing and transformation can occur.

A Framework for Culturally Relevant Online Learning: Lessons from Alaska's Tribal Health Workers

Culturally relevant health promotion is an opportunity to reduce health inequities in diseases with modifiable risks, such as cancer. Alaska Native people bear a disproportionate cancer burden, and Alaska's rural tribal health workers consequently requested cancer education accessible online. In response, the Alaska Native Tribal Health Consortium cancer education team sought to create a framework for culturally relevant online learning to inform the creation of distance-delivered cancer education. Guided by the principles of community-based participatory action research and grounded in empowerment theory, the project team conducted a focus group with 10 Alaska Native education experts, 12 culturally diverse key informant interviews, a key stakeholder survey of 62 Alaska Native tribal health workers and their instructors/supervisors, and a literature review on distance-delivered education with Alaska Native or American Indian people. Qualitative findings were analyzed in Atlas.ti, with common themes presented in this article as a framework for culturally relevant online education. This proposed framework includes four principles: collaborative development, interactive content delivery, contextualizing learning, and creating connection. As an Alaskan tribal health worker shared "we're all in this together. All about conversations, relationships. Always learn from you/with you, together what we know and understand from the center of our experience, our ways of knowing, being, caring." The proposed framework has been applied to support cancer education and promote cancer control with Alaska Native people and has motivated health behavior change to reduce cancer risk. This framework may be adaptable to other populations to guide effective and culturally relevant online interventions.

Human Seroprevalence to 11 Zoonotic Pathogens in the U.S. Arctic, Alaska

Background: Due to their close relationship with the environment, Alaskans are at risk for zoonotic pathogen infection. One way to assess a population's disease burden is to determine the seroprevalence of pathogens of interest. The objective of this study was to determine the seroprevalence of 11 zoonotic pathogens in people living in Alaska. Methods: In a 2007 avian influenza exposure study, we recruited persons with varying wild bird exposures. Using sera from this study, we tested for antibodies to Cryptosporidium spp., Echinococcus spp., Giardia intestinalis, Toxoplasma gondii, Trichinella spp., Brucella spp., Coxiella burnetii, Francisella tularensis, California serogroup bunyaviruses, and hepatitis E virus (HEV). Results: Eight hundred eighty-seven persons had sera tested, including 454 subsistence bird hunters and family members, 160 sport bird hunters, 77 avian wildlife biologists, and 196 persons with no wild bird exposure. A subset (n = 481) of sera was tested for California serogroup bunyaviruses. We detected antibodies to 10/11 pathogens. Seropositivity to Cryptosporidium spp. (29%), California serotype bunyaviruses (27%), and G. intestinalis (19%) was the most common; 63% (301/481) of sera had antibodies to at least one pathogen. Using a multivariable logistic regression model, Cryptosporidium spp. seropositivity was higher in females (35.7% vs. 25.0%; p = 0.01) and G. intestinalis seropositivity was higher in males (21.8% vs. 15.5%; p = 0.02). Alaska Native persons were more likely than non-Native persons to be seropositive to C. burnetii (11.7% vs. 3.8%; p = 0.005) and less likely to be seropositive to HEV (0.4% vs. 4.1%; p = 0.01). Seropositivity to Cryptosporidium spp., C. burnetii, HEV, and Echinococcus granulosus was associated with increasing age (p ≤ 0.01 for all) as was seropositivity to ≥1 pathogen (p < 0.0001). Conclusion: Seropositivity to zoonotic pathogens is common among Alaskans with the highest to Cryptosporidium spp., California serogroup bunyaviruses, and G. intestinalis. This study provides a baseline for use in assessing seroprevalence changes over time.

Prevalence and diversity of avian blood parasites in a resident northern passerine

BACKGROUND

Climate-related changes are expected to influence the prevalence and distribution of vector-borne haemosporidian parasites at northern latitudes, although baseline information about resident birds is still lacking. In this study, we investigated prevalence and genetic diversity of Plasmodium, Haemoproteus, and Leucocytozoon parasites infecting the northwestern crow (Corvus caurinus), a non-migratory passerine with unique life-history characteristics. This species occupies both intertidal and forested habitats and is subject to high prevalence of avian keratin disorder (AKD), a disease that causes gross beak deformities. Investigation of avian blood parasites in northwestern crows at sites broadly distributed across coastal Alaska provided an opportunity to evaluate specific host factors related to parasite infection status and assess geographical patterns of prevalence.

RESULTS

We used molecular methods to screen for haemosporidian parasites in northwestern crows and estimated genus-specific parasite prevalence with occupancy modeling that accounts for imperfect detection of parasite infection. We observed considerable geographical and annual variation in prevalence of Plasmodium, Haemoproteus, and Leucocytozoon, but these patterns were not correlated with indices of local climatic conditions. Our models also did not provide support for relationships between the probability of parasite infection and body condition or the occurrence of co-infections with other parasite genera or clinical signs of AKD. In our phylogenetic analyses, we identified multiple lineages of each parasite genus, with Leucocytozoon showing greater diversity than Plasmodium or Haemoproteus.

CONCLUSIONS

Results from this study expand our knowledge about the prevalence and diversity of avian blood parasites in northern resident birds as well as corvids worldwide. We detected all three genera of avian haemosporidians in northwestern crows in Alaska, although only Leucocytozoon occurred at all sites in both years. Given the strong geographical and annual variation in parasite prevalence and apparent lack of correlation with climatic variables, it appears that there are other key factors responsible for driving transmission dynamics in this region. Thus, caution is warranted when using standard climatic or geographical attributes in a predictive framework. Our phylogenetic results demonstrate lower host specificity for some lineages of Leucocytozoon than is typically reported and provide insights about genetic diversity of local haemosporidian parasites in Alaska.

BioRad BioPlex® HIV Ag-Ab assay: Incidence of false positivity in a low-prevalence population and its effects on the current HIV testing algorithm

BACKGROUND

The BioPlex® HIV Ag-Ab assay, unlike other HIV 1/2 antigen/antibody immunoassays, is capable of differentiating positive HIV-1 antibodies (Groups M and O) from HIV-2 antibodies and/or HIV-1 p24 antigen in a single test.

OBJECTIVE

The Alaska State Virology Laboratory (ASVL) adopted the BioPlex® HIV Ag-Ab assay early 2017 and can report on its performance in terms of false positivity in a low-prevalence population and its effects on the current HIV testing algorithm recommended by the Centers for Disease Control and Prevention (CDC).

STUDY DESIGN

Specimens received between March 2017 and August 2018 were screened using the BioPlex® HIV Ag-Ab assay. Specimens screening positive for HIV antibodies or antigen were further confirmed using the Geenius™ HIV 1/2 Supplemental Assay and/or HIV RNA testing.

RESULTS

Of the 12,338 sera screened by the BioPlex assay for HIV, 35 specimens were positive. Only 22 of the specimens were confirmed by supplemental testing and were considered to be truly positive (PPV, 62.9%). RNA was not detected in these cases suggesting initial false positivity on the BioPlex® HIV Ag-Ab assay. True positive results had index values (IDX) of >180 whereas false positive IDX's were between 1 and 4, with the exception of one specimen.

CONCLUSIONS

We suggest that specimens demonstrating positivity with low IDX values <4 on the BioPlex® HIV Ag-Ab assay proceed directly to RNA testing, essentially bypassing supplemental antibody confirmation tests, to reduce turnaround time and cost of HIV confirmation.

Patterns of Polysubstance Use Among Non-Hispanic White and American Indian/Alaska Native Adolescents: An Exploratory Analysis

INTRODUCTION

The prevalence of polysubstance use is well described, but less is known about correlates and patterns of polysubstance use. Previous research characterized latent subgroups of substance users by the type substance used. Racial disparities in the prevalence of polysubstance use exist, particularly for American Indian/Alaska Native (AI/AN) populations. The objective of our study was to describe differences in patterns of polysubstance use between non-Hispanic white and AI/AN adolescents.

METHODS

We obtained data from the 2013 Youth Risk Behavior Survey (YRBS). We analyzed substance use patterns (cigarettes, alcohol, marijuana, cocaine, inhalants, heroin, methamphetamines, ecstasy, steroids, and injected drugs) separately among 375 AI/AN and 15,633 non-Hispanic white adolescents. We calculated pairwise correlations. Exploratory factor analysis identified latent factors of polysubstance use patterns.

RESULTS

The use of all substances by AI/AN adolescents was the same or higher than use by non-Hispanic white adolescents, particularly for cocaine, heroin, and steroids. We found strong correlations between use of heroin and injected drugs and between use of cocaine and ecstasy among both populations. We found a latent factor for cigarettes, alcohol, and marijuana and another factor for broad polysubstance use among both populations. We found a factor for steroids and injected drugs among AI/AN adolescents, a factor for cocaine and ecstasy among non-Hispanic white adolescents, and a unique factor for methamphetamines.

CONCLUSION

Differences in substance use patterns exist between AI/AN and non-Hispanic white adolescents, particularly for illegal drug use. If validated in future research, information on these differences could be used to inform tailored intervention programs aimed at preventing substance use.

Timeliness of Breast Cancer Treatment Within The Alaska Tribal Health System

PURPOSE

This study examined the time from breast cancer diagnosis to initiation of treatment among Alaska Native (AN) women. We evaluated the impact of age, cancer stage, and rural/urban residence at diagnosis.

METHODS

We evaluated characteristics of women recorded in the Alaska Native Tumor Registry who received a first diagnosis of breast cancer between 2009 and 2013. Median time from diagnosis to treatment was assessed. Associations of demographic and clinical characteristics with timely initiation of treatment were evaluated using logistic regression and Cox proportional hazards models.

RESULTS

Two hundred seventy-eight (278) AN women were diagnosed with invasive breast cancer in years 2009-2013. Mean age at diagnosis was 56.8 years (SD = 13.0). The median time from diagnosis to initiation of treatment was 23 days (P < .05) with most (94.6%, n = 263) meeting the ≤60-day guideline target. Time to treatment was not associated with rural/urban residence, age, or stage at cancer diagnosis.

CONCLUSION

These findings indicate that most AN women diagnosed with breast cancer within the AN Tribal Health System receive timely treatment after diagnosis.

Biomarker feedback intervention for smoking cessation among Alaska Native pregnant women: Randomized pilot study

OBJECTIVE

There is some evidence for biomarker feedback when combined with cessation counseling for reducing smoking in pregnancy. This randomized controlled pilot study evaluated feasibility and potential efficacy of a social-cognitive theory (SCT)-based biomarker feedback intervention among pregnant Alaska Native (AN) smokers.

METHODS

Participants were randomly assigned to receive three study calls (10-20 min each): (1) biomarker feedback intervention (n = 30) including personalized cotinine results and feedback on their baby's likely exposure to carcinogen metabolite NNAL, or (2) contact control usual care condition based on the 5As (n = 30). Assessments were conducted at baseline, post-treatment, and delivery.

RESULTS

High rates of treatment compliance, study retention, and treatment acceptability were observed in both groups. 7-day point prevalence smoking abstinence rates at delivery verified with urinary cotinine were the same in both study groups (20% intent-to-treat analysis, 26% per-protocol). SCT-based measures did not change differentially from baseline by study group.

CONCLUSION

This trial supports the feasibility and acceptability of providing biomarker feedback within the clinical care delivery system, but the intervention did not promote increased smoking cessation during pregnancy compared to usual care.

PRACTICE IMPLICATIONS

Efforts are needed to promote the usual care and to develop alternative biomarker feedback messaging for pregnant AN women.

Hearing Norton Sound: mixed methods protocol of a community randomised trial to address childhood hearing loss in rural Alaska

INTRODUCTION

Childhood hearing loss has implications for school achievement, economic outcomes and quality of life. This study will engage rural Alaska communities in research to improve the school hearing screening and referral process, partnering with stakeholders to develop a locally derived, evidence-based solution to improve timely identification and treatment of childhood hearing loss.

METHODS AND ANALYSIS

Mixed methods community randomised trial in 15 communities in the Norton Sound region of northwest Alaska. Data collection will span from April 2017 until February 2020. Qualitative and mixed methods components are described in this protocol and the community randomised trial in the companion protocol. Focus groups and community events will be held leading up to the randomised trial to obtain community perspectives on childhood hearing loss in Alaska and elicit community input during trial protocol refinement (exploratory sequential stage). Stakeholder groups, including parents, children, teachers, school administrators and community health aides, will participate, along with community leaders, tribal leaders and community members. The randomised trial will be combined with qualitative, semi-structured interviews to elicit stakeholder perspectives on the intervention (explanatory sequential stage). The five stakeholder groups described above will participate in interviews. The study will conclude with additional focus groups and community events to discuss results and provide community insight for future implementation. Concluding focus groups will include policymakers, healthcare administrators, and tribal and community leaders in addition to the stakeholder groups. Informed consent and child assent will be required. Recordings will be transcribed and deidentified, with only stakeholder group recorded. Analyses will include categorical coding as well as narrative and thematic analysis.

ETHICS AND DISSEMINATION

The Hearing Norton Sound study has been approved by the Institutional Review Boards of Alaska Area, Norton Sound, and Duke University, with trial registration on clinicaltrials.gov. Study results will be distributed with equal emphasis on scientific and community dissemination.

TRIAL REGISTRATION NUMBER

NCT03309553; Results.

Hearing Norton Sound: a community randomised trial protocol to address childhood hearing loss in rural Alaska

INTRODUCTION

The population in rural Alaska experiences a disproprionately high burden of infection-mediated hearing loss. While the state mandates school hearing screening, many children with hearing loss are not identified or are lost to follow-up before ever receiving treatment. A robust, tribally owned healthcare system exists in Alaska, but children with hearing loss must first be identified and referred for existing infrastructure to be used. This trial will evaluate a new school hearing screening and referral process in rural Alaska, with the goal of improving timely identification and treatment of childhood hearing loss.

METHODS AND ANALYSIS

Comparative effectiveness community randomised trial testing digital innovations to improve school hearing screening and referral in 15 communities in the Norton Sound region of northwest Alaska, with data collection from October 2017 to February 2020. All children (K-12) attending school in Bering Strait School District with parental informed consent and child assent will be eligible (target recruitment n=1500). Participating children will undergo both the current school hearing screen and new mobile health (mHealth) screen, with screening test validity evaluated against an audiometric assessment. Communities will be cluster randomised to continue the current primary care referral process or receive telemedicine referral for follow-up diagnosis and treatment. The primary outcome will be time to International Statistical Classification of Diseases, 10th Revision, ear/hearing diagnosis from screening date, measured in days. Secondary outcomes will include: sensitivity and specificity of current school and mHealth screening protocols measured against a benchmark audiometric assessment (air and bone conduction audiometry, tympanometry and digital otoscopy); hearing loss prevalence; hearing-related quality of life; and school performance (AIMSweb). Intention-to-treat analysis will be used.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Boards of Alaska Area, Norton Sound and Duke University and is registered on clinicaltrials.gov. Results will be distributed with equal emphasis on scientific and community dissemination.

TRIAL REGISTRATION NUMBER

NCT03309553; Pre-results.

H. pylori-associated pathologic findings among Alaska native patients

Helicobacter pylori infection is common among Alaska native (AN) people, however scant gastric histopathologic data is available for this population. This study aimed to characterise gastric histopathology and H. pylori infection among AN people. We enrolled AN adults undergoing upper endoscopy. Gastric biopsy samples were evaluated for pathologic changes, the presence of H. pylori, and the presence of cag pathogenicity island-positive bacteria. Of 432 persons; two persons were diagnosed with gastric adenocarcinoma, two with MALT lymphoma, 40 (10%) with ulcers, and 51 (12%) with intestinal metaplasia. Fifty-five per cent of H. pylori-positive persons had cag pathogenicity island positive bacteria. The gastric antrum had the highest prevalence of acute and chronic moderate-severe gastritis. H. pylori-positive persons were 16 and four times more likely to have moderate-severe acute gastritis and chronic gastritis (p < 0.01), respectively. An intact cag pathogenicity island positive was correlated with moderate-severe acute antral gastritis (53% vs. 31%, p = 0.0003). H. pylori-positive persons were more likely to have moderate-severe acute and chronic gastritis compared to H. pylori-negative persons. Gastritis and intestinal metaplasia were most frequently found in the gastric antrum. Intact cag pathogenicity island positive was correlated with acute antral gastritis and intestinal metaplasia.