Knowledge, Attitudes, Beliefs, Practices Regarding Human Papillomavirus (HPV), and Barriers to Vaccination Against HPV Infection: A Cross-Sectional Survey of Guam Residents

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and is linked to several cancers. In Guam, the HPV vaccination rate falls short of the National Healthy People 2030 goal. Only half of eligible Guam teens have received the HPV vaccination series. Additionally, research on Guam HPV vaccination is limited. A cross-sectional survey was conducted, and a representative sample of Guam residents (n=775) was surveyed to examine their knowledge, attitudes, beliefs, practices regarding HPV, and barriers to HPV vaccination. Aggregated scores were calculated for these scale items: attitude, knowledge, subjective norms, and perceived behavioral control regarding HPV. One-way Analysis of Variance (ANOVA) was used to compare the means of the scores and check for significant differences. Binary logistic regression helped to identify significant predictors of HPV vaccination among respondents with children. Significant differences were found for sex, education, income, and ethnicity. Women and those with higher education and income demonstrated higher positive attitudes and knowledge about HPV vaccination. Also, those with health insurance and those who were advised by their physician were more likely to get their children vaccinated. These results will guide the implementation of effective strategies for developing targeted behavioral and other appropriate interventions to increase HPV vaccination in Guam.

Disparities in Colorectal Cancer Incidence among Asian and Pacific Islander Populations in Guam, Hawai'i, and the United States

Colorectal cancer (CRC) ranks among the three most common cancers in Guam (GU), Hawai'i (HI), and the mainland United States (US). CRC prevalence in these areas is high among Filipinos, and indigenous CHamorus and Native Hawaiians; however, data on these populations are frequently aggregated in epidemiological studies, which can mask true CRC disparities. We examined CRC cumulative incidence rates (CIRs) among CHamorus in GU, Filipinos in GU, HI, and the US, and Native Hawaiians in HI and the US. CRC CIRs were calculated for two age groups (20-49 years; early onset, and 50-79 years; senior) and four time periods (2000-2004, 2005-2009, 2010-2014, and 2015-2019), stratified by ethnicity, sex, and location. Data analyzed included all invasive CRC cases reported to the Surveillance, Epidemiology, and End Results 9-Registry (n = 166,666), the Hawai'i Tumor Registry (n = 10,760), and the Guam Cancer Registry (n = 698) between 2000 and 2019. Senior CIRs were highest in HI and lowest in GU throughout all time periods, with a downward trend observed for senior CIRs in the US and HI, but not GU. This downward trend held true for all ethnic groups, except for CHamorus in GU, females in GU, and females of CHamoru ethnicity in GU. In contrast, early onset CIRs increased across all locations, sexes, and ethnic groups, except for Filipinos in HI and males of Filipino ethnicity in HI. Our findings provide crucial insights for future research and policy development aimed at reducing the burden of CRC among indigenous populations.

Guam Adolescents' Use of Strategies to Resist Cigarette, e-Cigarette, and Betel Nut Offers: Findings from a Focus Group Study

Background: This study examined resistance strategies used by predominantly Pacific Islander young adolescents in response to offers of tobacco, e-cigarettes, and betel [areca] nuts. This study was intended to inform the development of a prevention curriculum focused on training young adolescents from the U.S.-Affiliated Pacific Islands (USAPI) on culturally appropriate strategies to resist substance use offers. Currently, very little is understood in terms of how Pacific Islander youths deal with tobacco and other substance use offers, although the use of tobacco products among Pacific Islander youths is high. Specifically, given the collectivist sociocultural orientation of the Pacific Islander communities, it is unclear whether the direct (overt) confrontational style of resistance is a viable mode of resistance for youths to practice when faced with a substance use offer. Methods: We conducted 10 focus groups with public middle school students (N = 34) from Guam, which is part of the USAPI. Results: Results suggested that, as with other communities in the U.S., the resistance strategies fall into two categories-overt/confrontational and non-confrontational resistance strategies. Overt/confrontational strategies included (a) saying "no" and (b) verbally confronting the offeror. Non-confrontational strategies included (a) avoiding or leaving the situation and (b) telling an adult. Conclusions: Our findings have implications for the development of culturally grounded interventions aimed at preventing youth tobacco and other substance use in Guam, the USAPI, and the Pacific region.

Perceived Barriers and Benefits of COVID-19 Testing among Pacific Islanders on Guam

Pacific Islanders residing in the U.S. Affiliated Pacific Islands have had among the highest COVID-19-associated morbidity and mortality rates in the U.S. To reduce this disparity, we conducted a study to increase the reach and uptake of COVID-19 testing in Guam. Participants, who completed a pre-survey on demographics, health status, history of COVID-19 testing and vaccination, access to COVID-19 testing, sources of COVID-19 information, and knowledge and attitudes towards COVID-19 test results and transmission, were invited to attend an online educational session about COVID-19 testing and transmission and to complete a post-survey. There were significant positive changes between pre- and post-survey in knowledge and perceptions about COVID-19 testing and transmission, but changes were not necessarily due to exposure to the educational session. Compared to CHamoru participants (n = 380), Other Micronesians (n = 90) were significantly less knowledgeable about COVID-19 transmission and testing, were significantly more likely to not want to know if they had COVID-19, were more likely to believe if they did have COVID-19 there was not much that could be done for them, and that they would have difficulty in getting the needed healthcare. This study is another example of disparities in health knowledge and perceptions of certain Pacific Islander groups.

Guam ALS-PDC is a distinct double-prion disorder featuring both tau and Aβ prions

The amyotrophic lateral sclerosis-parkinsonism dementia complex (ALS-PDC) of Guam is an endemic neurodegenerative disease that features widespread tau tangles, occasional α-synuclein Lewy bodies, and sparse β-amyloid (Aβ) plaques distributed in the central nervous system. Extensive studies of genetic or environmental factors have failed to identify a cause of ALS-PDC. Building on prior work describing the detection of tau and Aβ prions in Alzheimer's disease (AD) and Down syndrome brains, we investigated ALS-PDC brain samples for the presence of prions. We obtained postmortem frozen brain tissue from 26 donors from Guam with ALS-PDC or no neurological impairment and 71 non-Guamanian donors with AD or no neurological impairment. We employed cellular bioassays to detect the prion conformers of tau, α-synuclein, and Aβ proteins in brain extracts. In ALS-PDC brain samples, we detected high titers of tau and Aβ prions, but we did not detect α-synuclein prions in either cohort. The specific activity of tau and Aβ prions was increased in Guam ALS-PDC compared with sporadic AD. Applying partial least squares regression to all biochemical and prion infectivity measurements, we demonstrated that the ALS-PDC cohort has a unique molecular signature distinguishable from AD. Our findings argue that Guam ALS-PDC is a distinct double-prion disorder featuring both tau and Aβ prions.

Suicide risk and prevention in Guam: Clinical and research considerations and a call to action

The suicide rate in Guam, a United States (U.S.) territory, is markedly higher than the suicide rate within the U.S. There are also important differences in who is most at risk for suicide in Guam, relative to within the general U.S. Understanding these distinctions is important for implementing effective suicide prevention initiatives in this region. In the current article, we discuss considerations for preventing suicide in Guam, including distinctions in suicide risk, relative to within the general U.S. For example, suicide rates in Guam are highest for those who are Pacific Islander, young, or male. Further, suicide in Guam more commonly involves hanging and less commonly involves firearms, a pattern that differs from suicide methods used within the general U.S. Additional considerations include the large military and Veteran population in Guam, as well as cultural and religious beliefs regarding suicide. Finally, given the geographic isolation of Guam, access to healthcare is likely an important facet of suicide risk. Considering these characteristics, it is imperative to develop and implement culturally-sensitive suicide prevention interventions for individuals residing in this region. We conclude by discussing future research avenues to address critical knowledge gaps to prevent suicide in Guam.

Chronic BMAA exposure combined with TDP-43 mutation elicits motor neuron dysfunction phenotypes in mice

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with an average age-of-onset of ∼60 years and is usually fatal within 2-5 years of diagnosis. Mouse models based upon single gene mutations do not recapitulate all ALS pathological features. Environmental insults may also contribute to ALS, and β-N-methylamino-L-alanine (BMAA) is an environmental toxin linked with an increased risk of developing ALS. BMAA, along with cycasin, are hypothesized to be the cause of the Guam-ALS epicenter of the 1950s. We developed a multihit model based on low expression of a dominant familial ALS TDP-43 mutation (Q331K) and chronic low-dose BMAA exposure. Our two-hit mouse model displayed a motor phenotype absent from either lesion alone. By LC/MS analysis, free BMAA was confirmed at trace levels in brain, and were as high as 405 ng/mL (free) and 208 ng/mL (protein-bound) in liver. Elevated BMAA levels in liver were associated with dysregulation of the unfolded protein response (UPR) pathway. Our data represent initial steps towards an ALS mouse model resulting from combined genetic and environmental insult.

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.

Knowledge and Attitudes of Guam Residents towards Cancer Clinical Trial Participation

(1) Background: Currently there are no cancer clinical trials in Guam, where CHamoru people suffer the highest rates of cancer mortality, and interest to do so is growing. This study investigated the knowledge and attitudes of Guam residents towards cancer clinical trial participation prior to implementation. (2) Methods: A telephone survey was developed, tested, and conducted among Guam resident adults, 18 years of age and older. Survey questions were summarized by descriptive statistics. Logistic regression models were used to investigate the associations between Guam residents' demographics and their clinical trial knowledge and attitudes. Adjusted odds ratios (aOR) and associated 95% confidence intervals (CI) were calculated. (3) Results: One hundred fifty-two people participated in the survey, most of whom were CHamoru (47.0%). Fifty-three percent had heard the term 'clinical trial'; 73.7% would take part in a trial if they had cancer; and 59.9% believed they would receive good quality treatment from a trial offered in Guam. CHamoru were more likely than Whites to associate out-of-pocket expenses with clinical trial participation (aOR = 5.34, 95% CI = 1.68-17.00). Physician ethnicity was important to 30% of non-Whites and significantly associated with those who spoke a language other than English (aOR = 3.40, 95% CI = 1.29-8.95). Most people (65.0%) did not believe clinical trials participants were 'guinea pigs'. (4) Conclusion: Though knowledge about cancer clinical trials is limited, attitudes were primarily positive towards participating in cancer clinical trials offered in Guam. Future delivery of cancer clinical trials will benefit from identifying potential barriers to recruitment and adopting an approach suited to Guam's population.

Nutrient thresholds to protect water quality, coral reefs, and nearshore fisheries

A ridge-to-reef framework was developed for 26 watersheds around Guam. Dissolved inorganic nitrogen (DIN) data were collected for one year at the base of streams while coral and fish surveys were conducted on adjacent reefs. Two independent analyses revealed a similar 0.10 mg/l DIN threshold beyond which negative impacts to water quality and coral reefs existed. The influence of DIN was next partitioned with respect to a second primary stressor, fishing pressure. While coral diversity was negatively influenced by DIN, the cover of some stress-tolerant corals increased, such as Porites rus, making coral cover alone a poor indicator of watershed pollution. Less intuitive, DIN predicted increased food-fish biomass that was accounted for by generalist herbivores/detritivores, representing homogenized assemblages, while fishing pressure reduced biomass. Our DIN thresholds resonated with a similar study in American Samoa suggesting broader guidance for water quality legislation may be emerging.

Metals and Metalloids Increase in Cycas micronesica Seed Gametophyte Tissue in Shaded Growth Conditions

Exposure to environmental toxins may be partly responsible for mammal neurodegenerative disorders. Consumption of seeds from Guam's cycad tree has been linked to the disorder known as amyotrophic lateral sclerosis-parkinsonism dementia complex (ALS-PDC). The unambiguous identification of causal agents of ALS-PDC has been elusive. We have examined the levels of eight metals and metalloids in cycad seeds as a function of the ambient shade in which the plants were grown. Of these metals, the data strongly suggest that aluminum (Al) and selenium (Se) are present in washed flour prepared from southern Guam's cycad seed tissues at elevated levels, especially when the trees are grown in shade. Previous authors have speculated that Al and Se are involved in various ALS outcomes, and our results support this interpretation.

Temporal Variation of Litterfall and Nutrient Return of Serianthes nelsonii Merr. in a Tropical Karst Forest

Trees contribute to ecosystem nutrient cycling through the amount, timing, and composition of litterfall. Understanding the nature of this contribution from endangered tree species may aid in species and habitat recovery efforts. Serianthes nelsonii is an endangered tree species from the Mariana Islands, and little is known about litterfall dynamics. The timing of leaf, fruit, and stem litterfall was determined to more fully understand the return of nutrients via litter. The total annual litterfall was 272.8 g·m−2, with 45% represented by leaves, 48% represented by stems, and 7% represented by fruits. Stem litterfall weight contrasted more from month to month than the other organs, and leaf litterfall exhibited the most even distribution throughout the year. The timing of fruit and stem litterfall was influenced by the timing of extreme wind events. Leaf litter contributed nutrients in the following order: carbon > calcium > nitrogen > potassium > magnesium > iron > phosphorus > manganese > boron > zinc > copper. Fruit and stem litter contributed nutrients in the following order: carbon > calcium > nitrogen > magnesium > potassium > phosphorus > iron > manganese > boron > zinc > copper. Based on carbon/nitrogen, the stem litter exhibited the lowest quality and leaf litter exhibited the highest quality for speed of nutrient release via decomposition. Conservationists may use this knowledge to more fully integrate S. nelsonii trees into habitat management plans.

Changes in coral reef community structure along a sediment gradient in Fouha Bay, Guam

High sedimentation rates have well-documented, deleterious impacts on coral reefs. However, few previous studies have attempted to quantitatively describe a coral reef community across a large continuous sediment gradient. In this study distinct benthic assemblages in Fouha Bay, Guam, were identified using a Moving Window Analysis conducted along a two-order of magnitude sediment gradient, with transition boundaries that were generally consistent with sediment thresholds identified in the literature. Coral richness dropped exponentially with increasing sedimentation rate. Richness was nearly three times greater in assemblages with sedimentation rates <10 mg cm^-2 d^-1 compared to assemblages experiencing rates between 10 and 50 mg cm^-2 d^-1, and nearly 30 times greater than assemblages experiencing rates between 50 and 100 mg cm^-2 d^-1. No corals were found in assemblages with sedimentation rates >110 mg cm^-2 d^-1. Reducing sedimentation in this area could result in a shift of more diverse and abundant coral assemblages toward the head of the bay.

Pacific Islands Cohort on Cardiometabolic Health Study: rationale and design

Background

Pacific Islanders, including those residing in the US Affiliated Pacific Islands (USAPI), experience some of the highest mortality rates resulting from non-communicable diseases (NCDs) worldwide. The Pacific Island Health Officers’ Association declared a Regional State of Health Emergency in 2010 due to the epidemic of NCDs in the USAPI. Obesity, a known risk factor for NCDs, has become an epidemic among both children and adults in Micronesia and other parts of the USAPI. There is some recent information about overweight and obesity (OWOB) among young children in the USAPI, but there is no data looking at the relationship between children and their biological parents. The Pacific Islands Cohort on Cardiometabolic Health (PICCAH) Study aims to collect data on NCD lifestyle factors from two generations of families (n = 600 child-parent dyads or 1,200 participants) living in Guam, Pohnpei, and Palau.

Methods

The PICCAH Study is an epidemiological study using community-based convenience sampling to recruit participants in USAPI of Guam, Palau, and Pohnpei. The goal is to recruit participant dyads consisting of 1 child plus their biological parent in Guam (500 dyads or 1,000 participants), Pohnpei (50 dyads or 100 participants), and Palau (50 dyads or 100 participants). All participants are having the following information collected: demographic, health, and lifestyle information; anthropometry; diet; physical activity; sleep; acanthosis nigricans; blood pressure; and serum levels of fasting plasma glucose, fasting insulin, glycated hemoglobin, total cholesterol, triglycerides, LDL, and HDL.

Discussion

The PICCAH Study is designed to establish the baseline of a generational epidemiologic cohort with an emphasis on cardiometabolic risk, and to better understand the extent of DM and CVD conditions and related risk factors of those living in the USAPI jurisdictions of Guam, Pohnpei, and Palau. This study also serves to further build research capacity in the underserved USAPI Region.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13783-9.

Effects of elevated temperature on reproduction and larval settlement in Leptastrea purpurea

As global ocean temperatures continue to rise, severe declines in coral reef health and diversity are reported on a global scale. Recovery of coral reefs relies on reproduction and increased rates of successful recruitment, which can vary tremendously across coral species. We investigated the effects of increased temperatures in the environment of parental colonies on larval production, size, settlement and survival, in the heat-resistant coral Leptastrea purpurea in Guam. Thanks to two tank experiments (eleven and four weeks, respectively) conducted over two consecutive years we found that larvae released by heat-treated parents (30 °C) were significantly smaller in size but greater in number, had normal settlement behavior and increased post-settlement survival rates compared to those released by control parent colonies (28 °C). We conclude that changes in the environment of parental L. purpurea colonies trigger an anticipatory maternal effect which leads to the release of preconditioned larvae with an increased chance of survival.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s00338-022-02241-y.

"No Man Is an Island": Perspectives of CHamorus in Guam on COVID-19

OBJECTIVES

Guam is a United States territory situated in the western Pacific Ocean with a multiethnic population numbering approximately 168,000. The CHamorus, who are the Indigenous people of Guam, make up 37%. In this study, we sought to explore CHamorus' perspectives on and experiences of COVID-19.

DESIGN

Interviews were conducted with 10 CHamoru adults in June-July 2020 via telephone for a larger study on understanding how the collective history of the CHamoru people is perceived relative to contemporary health beliefs and practices. This study is a secondary data analysis of questions that focused on COVID-19. We used thematic analysis techniques to analyze the data.

RESULTS

Three themes were identified: self and other, or "no man is an island"; trust in government; and focusing on the positives. A cross-cutting theme was commitment to the common welfare of the community through interconnectedness and inafa'maolek (doing good for others).

CONCLUSION

Results indicated that CHamorus recognized a balance between community and individual, the need to protect the vulnerable while also considering personal choice, and the implications of enforced social distancing on community and economic stability.

An immigrant family with Kii amyotrophic lateral sclerosis/parkinsonism-dementia complex

OBJECTIVES

Amyotrophic lateral sclerosis/parkinsonism-dementia complex (ALS/PDC) is a unique endemic on Guam island of the USA, the Kii Peninsula of Japan, and Papua state of Indonesia. The pathomechanism of ALS/PDC remains to be solved, although interaction between some environmental factors and genetic background is plausible. This is the first autopsy-proven immigrant family of ALS/PDC of the Kii Peninsula.

METHODS

A daughter and her father immigrated to the high incident area from outside the Kii Peninsula. The father developed ALS 18 years later after immigration, and his daughter also developed ALS 65 years after immigration. They showed pure ALS phenotype without parkinsonism and dementia.

RESULTS

The daughter was diagnosed neuropathologically with Kii ALS/PDC with multiple proteinopathies: tauopathy, α-synucleinopathy, and TDP-43 proteinopathy. Gene analysis of familial ALS-related genes, including C9orf72, showed no mutation.

DISCUSSION

The findings in an immigrant family established that certain environmental factors play a critical role in the pathogenesis of Kii ALS/PDC.

Evaluation of camera trap-based abundance estimators for unmarked populations

Estimates of species abundance are critical to understand population processes and to assess and select management actions. However, capturing and marking individuals for abundance estimation, while providing robust information, can be economically and logistically prohibitive, particularly for species with cryptic behavior. Camera traps can be used to collect data at temporal and spatial scales necessary for estimating abundance, but the use of camera traps comes with limitations when target species are not uniquely identifiable (i.e., "unmarked"). Abundance estimation is particularly useful in the management of invasive species, with herpetofauna being recognized as some of the most pervasive and detrimental invasive vertebrate species. However, the use of camera traps for these taxa presents additional challenges with relevancy across multiple taxa. It is often necessary to use lures to attract animals in order to obtain sufficient observations, yet lure attraction can influence species' landscape use and potentially induce bias in abundance estimators. We investigated these challenges and assessed the feasibility of obtaining reliable abundance estimates using camera-trapping data on a population of invasive brown treesnakes (Boiga irregularis) in Guam. Data were collected using camera traps in an enclosed area where snakes were subject to high-intensity capture-recapture effort, resulting in presumed abundance of 116 snakes (density = 23/ha). We then applied spatial count, random encounter and staying time, space to event, and instantaneous sampling estimators to photo-capture data to estimate abundance and compared estimates to our presumed abundance. We found that all estimators for unmarked populations performed poorly, with inaccurate or imprecise abundance estimates that limit their usefulness for management in this system. We further investigated the sensitivity of these estimators to the use of lures (i.e., violating the assumption that animal behavior is unchanged by sampling) and camera density in a simulation study. Increasing the effective distances of a lure (i.e., lure attraction) and camera density both resulted in biased abundance estimates. Each estimator rarely recovered truth or suffered from convergence issues. Our results indicate that, when limited to unmarked estimators and the use of lures, camera traps alone are unlikely to produce abundance estimates with utility for brown treesnake management.

Lytico-bodig in Guam: Historical links between diet and illness during and after Spanish colonization

This paper analyses documents on health and disease among Chamorro people during and after 333 years (1565-1898) of the Spanish claim to and occupation of Guam. Here, a complex neurodegenerative disease-known locally as lytico-bodig and medically as amyotrophic lateral sclerosis and Parkinsonism-dementia complex (ALS/PDC)-reached hyperendemic proportions in the mid-twentieth century but then declined and is now disappearing. A tau-dominated polyproteinopathy, clinical phenotypes included amyotrophic lateral sclerosis (ALS or lytico), atypical parkinsonism with dementia (P-D or bodig), and dementia alone. A plausible etiology for lytico-bodig is consumption of flour derived from the incompletely detoxified seed of Cycas micronesica (fadang in Chamorro; Federico in Spanish), a poisonous gymnosperm that survives climatic extremes that can affect the island. Traditional methods for safe consumption appear to have been lost over the course of time since governors Francisco de Villalobos (1796-1862) and Felipe de la Corte (1855-1866) proposed banning consumption in view of its acute toxic effects. A death certificate issued in 1823 might suggest ALS/PDC in people dying with disability or impedidos, and premature aging and a short life was linked to food use of fadang in the mid-1850s (Guam Vital Statistics Report, 1823). During the Japanese occupation of Guam (1941-1944), Chamorro people took refuge in the jungle for months, where they relied on insufficiently processed fadang as a staple food. After World War II, traditional foods and medicines were subsequently replaced as islanders rapidly acculturated to North American life.

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.

Pogostemon guamensis Lorence & W.L.Wagner (Lamiaceae), a new species from Guam, Mariana Islands

While undertaking a botanical survey of the Andersen Air Force Base on Guam (Mariana Islands) in 1994, botanists from the National Tropical Botanical Garden collected an unusual suffrutescent, non-aromatic member of the Lamiaceae family growing on limestone cliffs in the northeastern part of the island. Based on morphology and molecular data (trnLF, matK), it was determined to belong to the genus Pogostemon Desf., a genus previously unknown from the Micronesian, Melanesian, and Polynesian region. Moreover, the analysis also showed that it was not conspecific with P. cablin (patchouli), and of the species available to include in the phylogenetic analyses it is sister to P. hirsutus¸ a species from India and Sri Lanka. Differing from its congeners by its large, loose inflorescence 2.5-5 cm wide and up to 7 cm wide in fruit, it is here illustrated and described as a new species, Pogostemon guamensis Lorence & W.L. Wagner and its habitat and conservation status are discussed.

Bi-Pinnate Compound Serianthes nelsonii Leaf-Level Plasticity Magnifies Leaflet-Level Plasticity

Numerous leaf traits exhibit developmental plasticity in response to irradiance, an attribute that maximizes performance in the prevailing light. The use of leaflets to represent whole leaf traits of tree species with compound leaves is common in the acclimation literature. These methods ignore the potential for whole leaf plasticity to augment leaflet plasticity. We grew Serianthes nelsonii plants in incident light ranging from 6% to 100% of sunlight and quantified numerous leaflet and leaf traits to determine plasticity index (PI: (maximum-minimum)/maximum)) of each. Leaflet acclimation such as changes in length of palisade mesophyll occurred as expected. However, leaf-level morphometric traits such as rachillae insertion angle also exhibited acclimation potential. The leaf-level plastic behavior enabled acclimation approaches that simple-leaved species do not possess. We illuminate the need to look at the entire leaf when quantifying acclimation potential of tree leaves, and indicate that the historical use of leaflets to represent species with compound leaves under-estimated the acclimation potential when compared to species with simple leaves.

Prevalence and Predictors of Overweight and Obesity among Young Children in the Children's Healthy Living Study on Guam

This study is part of the Children's Healthy Living program in U.S. Affiliated Pacific region. The objectives were to estimate overweight and obesity (OWOB) prevalence and identify possible related risk factors among ethnic groups in Guam. In 2013, 865 children (2-8 years) were recruited via community-based sampling from select communities in Guam. Children's demographic and health behavior information; dietary intake; and anthropometric measurements were collected. Logistic regression, odds ratio, t-tests, and chi-square tests were used to determine differences and assess covariates of OWOB. The results indicate that 58% of children were living below the poverty level, 80% were receiving food assistance, and 51% experienced food insecurity. The majority of children surveyed did not meet recommendations for: sleep duration (59.6%), sedentary screen-time (83.11%), or fruit (58.7%) and vegetable (99.1%) intake, and consumed sugar sweetened beverages (SSB) (73.7%). OWOB affected 27.4% of children. Children affected by OWOB in this study were statistically more likely (p = 0.042) to suffer from sleep disturbances (p = 0.042) and consume marginally higher amounts (p value = 0.07) of SSB compared to children with healthy weight. Among Other Micronesians, children from families who considered themselves 'integrated' into the culture were 2.05 (CI 0.81-5.20) times more likely to be affected by OWOB. In conclusion, the OWOB prevalence among 2-8-year-olds in Guam was 27.4%; and compared with healthy weight children, children with OWOB were more likely to have educated caregivers and consume more SSBs. Results provide a basis for health promotion and obesity prevention guidance for children in Guam.

Etiology of Retinal and Cerebellar Pathology in Western Pacific Amyotrophic Lateral Sclerosis and Parkinsonism-Dementia Complex

Purpose

To reexamine the etiology of a unique retinal pathology (linear and vermiform sub-retinal tubular structures) described among subjects with and without neurodegenerative disease in former high-incidence foci of Western Pacific amyotrophic lateral sclerosis and parkinsonism-dementia complex (ALS/PDC) in Guam (USA) and the Kii peninsula of Honshu island (Japan).

Methods

Analysis of published and unpublished reports of 1) ALS/PDC and the retinal and cerebellar pathology associated therewith and 2) exogenous neurotoxic factors associated with ALS/PDC and the developing retina and cerebellum.

Results

ALS/PDC retinal and cerebellar pathology matches persistent retinal and cerebellar dysplasia found in laboratory animals given single in utero or postnatal systemic treatment with cycasin, the principal neurotoxic component in the seed of cycad plants traditionally used for food (Guam) or oral medicine (Kii-Japan), both of which have been linked to the human neurodegenerative disease.

Conclusion

ALS/PDC-associated retinal and cerebellar dysplasia could arise from in utero exposure to methylazoxymethanol, the genotoxic metabolite of cycasin that results from maternal ingestion of this azoxyglucoside. These results support the environmental toxic etiology of retinal and brain pathology in ALS/PDC.

An Instagram-Based Study to Understand Betel Nut Use Culture in Micronesia: Exploratory Content Analysis

BACKGROUND

A 2012 World Health Organization report recognizes betel nut use as an urgent public health threat faced by the Western Pacific region. However, compared with other addictive substances, little is known about how betel nuts are depicted on social media platforms. In particular, image-based social media platforms can be powerful tools for health communication. Studying the content of substance use on visual social media may provide valuable insights into public health interventions.

OBJECTIVE

This study aimed to explore and document the ways that betel nut is portrayed on the photo-sharing site Instagram. The analysis focuses on the hashtag #pugua, which refers to the local term for betel nut in Guam and other parts of Micronesia.

METHODS

An exploratory content analysis of 242 Instagram posts tagged #pugua was conducted based on previous research on substance use and Instagram and betel nut practices in Micronesia. In addition, the study examined the social engagement of betel nut content on the image-based platform.

RESULTS

The study findings revealed content themes referencing the betel nut or betel nut tree, betel nut preparation practices, and the unique social and cultural context surrounding betel nut activity in Guam and Micronesia. In addition, certain practices and cultural themes encouraged social engagement on Instagram.

CONCLUSIONS

The findings from this study emphasize the cultural relevance of betel nut use in Micronesia. These findings provide a basis for empirically testing hypotheses related to the etiological roles of cultural identity and pride in shaping betel nut use behavior among Micronesians, particularly youths and young adults. Such research is likely to inform the development of culturally relevant betel nut prevention and cessation programs.

Island Nation, US Territory and Contested Space: Territorial Status As a Social Determinant of Indigenous Health in Guam

The United Nations and International Federation of Social Work affirm the right of all people to determine their political status, preserve their environments and pursue endeavours for well-being. This article focuses on CHamoru, Guam's Indigenous people, and examines distal social determinants of health (SDOH) in the contested spaces of US territorial status and non-self-determining Indigenous nationhood. Published multi-disciplinary literature identified ways in which territorial status functions as an SDOH unique to non-self-determining Pacific Island nations. Indicated is the use of structural approaches that address mechanisms of US power and control, including economic policies that 'defacto' promote coca-colonisation and non-communicable diseases risk. Critical race theory centres race, colonisation and subversive narratives. In line with fourth-generation SDOH action-oriented research, we posit a CHamoru critical race theory model that weaves Indigenous, social work and public health perspectives. Lack of community input is a limitation of the current research. To assure relevance, the model will be vetted through community discussions. Our discussion guide may be tailored for other Indigenous communities. Social workers may play a meaningful role in promoting health equity through participatory action-oriented, cultural-political social work that upholds Indigenous self-determination and survivance in contested spaces.

Cumulative Incidence Rates of Breast Cancer by Age for Filipinos and Chamorros in Guam

Breast cancer is the second leading cause of cancer-related death among women on Guam and Hawai'i. Breast cancer incidence rates are described here for the multiethnic population in Guam, a United States (US) Pacific island territory, and compared to Hawai'i and other US populations, to understand the risk by age and race/ethnic group in this understudied group. The study included all breast cancer cases (n=576) reported to the Guam Cancer Registry, all breast cancer cases (n=8345) reported to the Hawai'i Tumor Registry and all breast cancer cases (n=678,637) reported to the Surveillance, Epidemiology, and End Results program from 2000 to 2009. Cumulative incidence rates by age were calculated for two time periods: 2000-2004 and 2005-2009. Differences were seen in cumulative incidence rates by age, ethnicity, and place of residence. Cumulative incidence rates by age 40 were the highest (0.7%) among Filipinos in Guam but, after age 40, the rates for Chamorros (indigenous Pacific Islanders of Guam) increased rapidly. The lifetime cumulative incidence rates were the highest for Chamorros in Guam (15.3%), close to the US rate (15.5%). Results were similar for 2005-2009. Women in Guam are at high risk for breast cancer, with the indigenous Chamorros having the highest risk, and the most prevalent Asian group of Filipinos, having a younger age at diagnosis. These patterns are similar to the comparable Pacific Islander and Filipino populations in Hawai'i and the US generally.

Diel patterns of stem CO2 efflux vary among cycads, arborescent monocots, and woody eudicots and gymnosperms

The diel patterns of stem carbon dioxide efflux (E_s) were determined for cycads, monocots, and woody eudicot and gymnosperm tree species. Stem E_s at a height of 30-40 cm was measured every 2 h throughout 31-h campaigns. Our range of E_s was 1.5-4.0 µmol·m^-2·s^-1 for cycads, 1.0-3.5 µmol·m^-2·s^-1 for arborescent monocots, and 1.5-4.5 µmol·m^-2·s^-1 for woody eudicot and gymnosperm trees species. Time of day did not influence E_s of cycads or monocots. In contrast, the woody stems of eudicots and gymnosperms exhibited diurnal E_s that was 36% to 40% greater than nocturnal E_s. The established literature based on E_s of woody tree species cannot be used to estimate habitat carbon cycles in habitats which contain cycad or monocot trees. Time of day must be included for accuracy of research on E_s of woody tree species. Failures to account for the spatiotemporal differences of E_s may explain some of the disparity in outcomes of published stem respiration studies.

Rationale and design of a randomized, controlled, superiority trial on areca nut/betel quid cessation: The Betel Nut Intervention Trial (BENIT)

Background

Areca nut (AN) is the seed endosperm of the Areca catechu L. palm and a Group 1 carcinogen chewed by 10–20% of the world population. AN is often chewed with Piper betle L. leaf, slaked lime, and tobacco to form a betel quid (BQ). The negative health effects associated with AN/BQ consumption warrant the need for an evidence-based cessation program. However, systematic research on AN/BQ cessation is rare.

Methods/design

The Betel Nut Intervention Trial (BENIT; trial #NCT02942745) is a randomized controlled trial designed to test the efficacy of an intensive AN/BQ cessation program. The trial is ongoing in Guam and Saipan with adult chewers who include tobacco in their BQ. Enrolled participants are assessed for their primary (chewing status) and secondary (saliva bio-verification) outcome at baseline, 22 days, and 6 months. Participants randomized into the control arm receive an educational booklet while those randomized into the intervention arm receive the educational booklet and a 22-day cessation program modeled after a smoking cessation program and led by trained facilitators. Information on chewing behavior (history, reasons for chewing, and AN/BQ composition and dependency) are collected. The intervention effectiveness is assessed using the logistic mixed model to compare cessation status between randomization groups.

Discussion

AN/BQ chewing affects a large population of people, many of whom live in low and moderate income countries in the Asia-Pacific region. Although the BENIT focuses on chewers in Guam and Saipan, it has the potential for greater regional and global importance.

Ethnic Inequalities in Psychological Distress: A Population Data Linkage Study on the Pacific Island of Guåhån/Guam

Psychological distress and mental illness has been found to be elevated in migrant groups living in sovereign countries, as well as for indigenous people living under colonial or administrative rule. The north Pacific island of Guam is unusual in its ethnic composition as it has no majority ethnic group, has a large indigenous population and remains a territory of the U.S. This study aimed to identify ethnic differences in self-reported psychological distress between the main ethnic groups on Guam. The study uses a cross sectional design with data linkage methodology, drawing on the Guam Census and the Behavioral Risk Factor Surveillance System health survey for Guam. The results showed that the native Chamorro population had worse self-reported psychological distress (defined as a 'mental health condition or emotional problem') than White/Caucasians (OR 2.09, 95% CI 1.52-2.87), particularly for severe distress (OR 3.61, 95% CI 1.33-2.77). This relationship persisted even after adjusting for a wide range of socio-demographic and economic factors (OR 2.58, 95% CI 1.15-5.76). Other Pacific Islanders also had higher psychological distress compared to White/Caucasians, but this association was largely explained by the adjusted factors. The findings are discussed in terms of social and economic disadvantage for Pacific Island peoples on Guam, as well as the impact of colonial administration, disaffection, and lack of autonomy for the Chamorro of Guam. Recommendations are made to improve psychiatric treatment for these groups by considering wider socio-political factors in assessment and treatment, as well as broader implications for the national dialogue on self-determination.

Racial and Ethnic Variations in Mortality Rates for Patients Undergoing Maintenance Dialysis Treated in US Territories Compared with the US 50 States

BACKGROUND AND OBJECTIVES

In the United States mortality rates for patients treated with dialysis differ by racial and/or ethnic (racial/ethnic) group. Mortality outcomes for patients undergoing maintenance dialysis in the United States territories may differ from patients in the United States 50 states.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective cohort study of using US Renal Data System data included 1,547,438 adults with no prior transplantation and first dialysis treatment between April 1, 1995 and September 28, 2012. Cox proportional hazards regression was used to calculate hazard ratios (HRs) of death for the territories versus 50 states for each racial/ethnic group using the whole cohort and covariate-matched samples. Covariates included demographics, year of dialysis initiation, cause of kidney failure, comorbid conditions, dialysis modality, and many others.

RESULTS

Of 22,828 patients treated in the territories (American Samoa, Guam, Puerto Rico, Virgin Islands), 321 were white, 666 were black, 20,299 were Hispanic, and 1542 were Asian. Of 1,524,610 patients in the 50 states, 838,736 were white, 444,066 were black, 182,994 were Hispanic, and 58,814 were Asian. The crude mortality rate (deaths per 100 patient-years) was lower for whites in the territories than the 50 states (14 and 29, respectively), similar for blacks (18 and 17, respectively), higher for Hispanics (27 and 16, respectively), and higher for Asians (22 and 15). In matched analyses, greater risks of death remained for Hispanics (HR, 1.65; 95% confidence interval, 1.60 to 1.70; P<0.001) and Asians (HR, 2.01; 95% confidence interval, 1.78 to 2.27; P<0.001) living in the territories versus their matched 50 states counterparts. There were no significant differences in mortality among white or black patients in the territories versus the 50 states.

CONCLUSIONS

Mortality rates for patients undergoing dialysis in the United States territories differ substantially by race/ethnicity compared with the 50 states. After matched analyses for comparable age and risk factors, mortality risk no longer differed for whites or blacks, but remained much greater for territory-dwelling Hispanics and Asians.

Examining the Influence of Cultural Immersion on Willingness to Try Fruits and Vegetables among Children in Guam: The Traditions Pilot Study

This pilot study examined the influence of cultural immersion on willingness to try fruits and vegetables (FV) among children 3-12 years old in three summer camps in Guam with different cultural exposure levels: cultural immersion camp (CIC), high exposure; university day camp (UDC), moderate exposure; and recreational sports camp (RSC), zero exposure. Children, ages 3-12 years old for CIC and UDC and 5-12 years old for RSC, participated: CIC (n = 47), UDC (n = 23), and RSC (n = 33). Children's willingness to try FV was assessed with the Adapted WillTry tool before and after each program. Whole FV intakes were assessed concurrently using the mobile food record in CIC and UDC. Using multivariate regression, WillTry post-assessment outcomes were modeled adjusting for pre-assessment, child characteristics, exposure, and parent cultural affiliation. Unique to the Adapted WillTry tool are three FV scales, local novel, local common, and imported, which are classified by source (local or imported) and/or familiarity (novel or common). WillTry adjusted mean FV post-scores by highest exposure camp to lowest were 2.2, 2.3, and 2.2 for local novel and 2.6, 2.6, and 2.6 for local common. No differences among camps were significant; however, there was an increase in the willingness to try scores for all FV score types and camps. The Traditions pilot study demonstrated: (1) feasibility of a multi-arm parallel design using existing community programs in limited-resource environments and (2) further examination of nutrition education components and contexts are needed to understand diet behaviors of indigenous populations.

A Unique Partnership Between the University of Hawai'i Cancer Center and the University of Guam: Fifteen Years of Addressing Cancer Health Disparities in Pacific Islanders in Hawai'i and Guam

This manuscript describes the efforts in research, education, and outreach of a unique partnership between the University of Hawai'i Cancer Center and the University of Guam in addressing cancer health disparities faced by Pacific Islanders in Hawai'i, Guam, and other parts of Micronesia. Significant accomplishments of this 15-year collaboration in research, training Micronesian students, and impact on the local communities are highlighted.

Life history, distribution and molecular phylogenetics of the Upward-Mouth Spikefish Atrophacanthus japonicus (Teleostei: Tetraodontiformes: Triacanthodidae)

Ninety-six juvenile specimens (37-54 mm standard length; L_S ) of the rarely collected Upward-Mouth Spikefish Atrophacanthus japonicus (Triacanthodidae) were obtained from the stomachs of three Yellowfin Tuna Thunnus albacares collected off Guam in the Mariana Islands in the central Pacific Ocean. These specimens extend the range of A. japonicus eastward into Oceania. We review the systematic characters of the monotypic genus Atrophacanthus and present colour photographs of freshly collected specimens. The diet of the juvenile specimens of A. japonicus consisted of thecosome pteropods and foraminiferans. We present a range map of A. japonicus based on all known specimens and show that specimen size is related to whether specimens were collected in the pelagic zone or on the bottom. Our results support that, compared to all other Triacanthodidae, A. japonicus has an unusually extended pelagic larval and juvenile period, up to 54 mm L_S , before settling to the bottom as adults. Lastly, we provide a multilocus phylogeny addressing the phylogenetic placement of Atrophacanthus based on eight of 11 triacanthodid genera and six genetic markers. Our results reveal that Atrophacanthus is the sister group of Macrorhamphosodes and they provide new insights about the evolutionary history of the family.

Embracing the Obstetric Imaginary: Chuukese Women, Migration, and Stratified Reproduction

When a new biomedical hospital was built in Chuuk, women were encouraged to forgo home births and seek obstetric care. Chuuk's infrastructure deteriorated over time, however, and the hospital became known as the place of death. Women maintained faith in obstetric technology despite these conditions; they simply sought better technology in Guam or a US state. Yet, even upon migrating, women continued to suffer disproportionately poor birth outcomes. In this article, I explore how Chuukese women maintained faith in obstetric technology, elucidating the power of the "obstetric imaginary" in the context of neocolonial development, migration, and stratified reproduction.

Opioid distribution trends (2006-2017) in the US Territories

Background

The US mainland is experiencing an epidemic of opioid overdoses. Unfortunately, the US Territories (Guam, Puerto Rico, and the Virgin Islands) have often been overlooked in opioid pharmacoepidemiology research. This study examined common prescription opioids over the last decade.

Methods

The United States Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (ARCOS) was used to report on ten medical opioids: buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, and oxymorphone, by weight from 2006 to 2017. Florida and Hawaii were selected as comparison areas.

Results

Puerto Rico had the greatest Territorial oral morphine mg equivalent (MME) per capita (421.5) which was significantly higher (p < .005) than the Virgin Islands (139.2) and Guam (118.9) but significantly lower than that of Hawaii (794.6) or Florida (1,509.8). Methadone was the largest opioid by MMEs in 2017 in most municipalities, accounting for 41.1% of the total in the Virgin Islands, 37.9% in Florida, 36.6% in Hawaii but 80.8% in Puerto Rico. Puerto Rico and Florida showed pronounced differences in the distribution patterns by pharmacies, hospitals, and narcotic treatment programs for opioids.

Conclusions

Continued monitoring of the US Territories is needed to provide a balance between appropriate access to these important agents for cancer related and acute pain while also minimizing diversion and avoiding the opioid epidemic which has adversely impacted the US mainland.

A Socio-Ecological Framework for Cancer Control in the Pacific: A Community Case Study of the US Affiliated Pacific Island Jurisdictions 1997-2017

The United States Affiliated Pacific Island Jurisdictions (USAPIJ) are politically associated to the United States (US) as US Territories (Guam, American Samoa), a US Commonwealth (Commonwealth of the Northern Mariana Islands), and as sovereign nations linked to the US through Compacts of Free Association [Federated States of Micronesia (FSM), Republic of the Marshall Islands (RMI), Republic of Palau (ROP)]. Cervical cancer incidence in the RMI is the highest in the world, mammography services are not available in the FSM and only Guam has on-island oncology services. Cancer risk factors such as obesity, tobacco, and Hepatitis B are prevalent. Twelve years of nuclear testing in the RMI adds to the cancer burden. A community-based, multi-national coalition with multi-system external partners the Pacific Regional Cancer Control Partnership (PRCP) was developed to address cancer prevention and control in the USAPIJ. Through the PRCP, local cancer coalitions, a regional cancer registry, 12 years of regional cancer control plans, and cancer prevention programs and research has been implemented. Methods: The PRCP is the subject of this community case study. The PRCP is analyzed through a socio-ecological theoretical framework to contextualize its typology, building blocks, and management. The respective roles and work of each partner and organization will be described and aligned with the levels of the socio-ecological framework. Results: The USAPIJs evolved a community-focused internal and external regional cancer prevention and control network over 20 years. The function and structure of the PRCP fits within a socio-ecological framework for cancer control. An adaptive management strategy has been used within the PRCP to manage its multi-national, multi-level, and multi-system partners. Conclusion: The PRCP has been able to advance cancer prevention and control programs with a community-centric model that functions in a multi-national, multi-cultural, low-resource, geographically dispersed environment over the last 20 years. The PRCP operates with a structure and management style that is consistent with a socio-ecological framework for cancer control. This case study provides a blueprint for the PRCP organizational structure and a mechanism for its function. The PRCP concept, a community-centric model for cancer control in multi-national resource-limited environments, may be scaled to other global environments.

Three-Finger Toxin Diversification in the Venoms of Cat-Eye Snakes (Colubridae: Boiga). J Mol Evol. 2018; Epub ahead of print. [PMID: 30206667 DOI: 10.1007/s00239-018-9864-6]

The Asian genus Boiga (Colubridae) is among the better studied non-front-fanged snake lineages, because their bites have minor, but noticeable, effects on humans. Furthermore, B. irregularis has gained worldwide notoriety for successfully invading Guam and other nearby islands with drastic impacts on the local bird populations. One of the factors thought to allow B. irregularis to become such a noxious pest is irditoxin, a dimeric neurotoxin composed of two three-finger toxins (3FTx) joined by a covalent bond between two newly evolved cysteines. Irditoxin is highly toxic to diapsid (birds and reptiles) prey, but roughly 1000 × less potent to synapsids (mammals). Venom plays an important role in the ecology of all species of Boiga, but it remains unknown if any species besides B. irregularis produce irditoxin-like dimeric toxins. In this study, we use transcriptomic analyses of venom glands from five species [B. cynodon, B. dendrophila dendrophila, B. d. gemmicincta, B. irregularis (Brisbane population), B. irregularis (Sulawesi population), B. nigriceps, B. trigonata] and proteomic analyses of B. d. dendrophila and a representative of the sister genus Toxicodryas blandingii to investigate the evolutionary history of 3FTx within Boiga and its close relative. We found that 92.5% of Boiga 3FTx belong to a single clade which we refer to as denmotoxin-like because of the close relation between these toxins and the monomeric denmotoxin according to phylogenetic, sequence clustering, and protein similarity network analyses. We show for the first time that species beyond B. irregularis secrete 3FTx with additional cysteines in the same position as both the A and B subunits of irditoxin. Transcripts with the characteristic mutations are found in B. d. dendrophila, B. d. gemmicincta, B. irregularis (Brisbane population), B. irregularis (Sulawesi population), and B. nigriceps. These results are confirmed by proteomic analyses that show direct evidence of dimerization within the venom of B. d. dendrophila, but not T. blandingii. Our results also suggest the possibility of novel dimeric toxins in other genera such as Telescopus and Trimorphodon. All together, this suggests that the origin of these peculiar 3FTx is far earlier than was appreciated and their evolutionary history has been complex.

Contrasting ecological roles of non-native ungulates in a novel ecosystem

Conservation has long focused on preserving or restoring pristine ecosystems. However, understanding and managing novel ecosystems has grown in importance as they outnumber pristine ecosystems worldwide. While non-native species may be neutral or detrimental in pristine ecosystems, it is possible that even notorious invaders could play beneficial or mixed roles in novel ecosystems. We examined the effects of two long-established non-native species-Philippine deer (Rusa marianna) and feral pigs (Sus scrofa)-in Guam, Micronesia, where native vertebrate frugivores are functionally absent leaving forests devoid of seed dispersers. We compared the roles of deer and pigs on seedling survival, seed dispersal and plant community structure in limestone karst forests. Deer, even at low abundances, had pronounced negative impacts on forest communities by decreasing seedling and vine abundance. By contrast, pigs showed no such relationship. Also, many viable seeds were found in pig scats, whereas few were found in deer scats, suggesting that pigs, but not deer, provide an ecosystem function-seed dispersal-that has been lost from Guam. Our study presents a discrepancy between the roles of two non-native species that are traditionally managed as a single entity, suggesting that ecological function, rather than identity as a non-native, may be more important to consider in managing novel systems.

Chuukese Patients, Dual Role Interpreters, and Confidentiality: Exploring Clinic Interpretation Services for Reproductive Health Patients

This exploratory study analyzes limited English proficient (LEP) Chuukese patients' perspectives on dual-role interpreters in Guam and Chuuk. Methods included ethnographic observations of encounters with health care workers (HCWs) and 225 female Chuukese patients seeking reproductive healthcare in community health clinics: 126 women in Guam and 99 women in Chuuk. Ethnographic observations were supplemented by semi-structured interviews with 26 HCWs, and life history interviews with 15 Chuukese transnational migrant women. Notes from interview transcripts and observations were analyzed using critical interpretive and grounded theory. Findings demonstrated that Chuukese LEP patients need and at times want interpreters in order to understand their healthcare visits. In the absence of professional interpreters, ad-hoc interpreters (family interpreters and employees of the clinic) are an important resource. However, social and cultural concerns with community confidentiality influenced patient trust of staff interpreters. This lack of trust can limit access to health care overall, as some patients may avoid seeking care to prevent their confidential health information being disclosed. These complexities in interpretation must be considered in order for clinics to provide optimal care for the communities they serve.

Risk factors for breast cancer in the breast cancer risk model study of Guam and Saipan

BACKGROUND

Chamorro Pacific Islanders in the Mariana Islands have breast cancer incidence rates similar to, but mortality rates higher than, those of U.S. women. As breast cancer risk factors of women of the Mariana Islands may be unique because of ethnic and cultural differences, we studied established and suspected risk factors for breast cancer in this unstudied population.

METHODS

From 2010-2013, we conducted retrospective case-control study of female breast cancer (104 cases and 185 controls) among women in the Mariana Islands. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each of various lifestyle-related factors from logistic regression of breast cancer, in all women and in pre- and postmenopausal women separately. Tests for interaction of risk factors with ethnicity were based on the Wald statistics for cross-product terms.

RESULTS

Of the medical and reproductive factors considered - age at menarche, breastfeeding, number of live births, age at first live birth, hormone use, and menopause - only age at first live birth was confirmed. Age at first live birth, among parous women, was higher among cases (mean 24.9 years) than controls (mean 23.2 years); with increased breast cancer risk (OR=2.53; 95% CI, 1.04-6.19 for age≥30y compared to <20y, P for trend=0.01). Of the lifestyle factors -body mass index, waist circumference, physical activity, alcohol and betel-nut intake, and education - only waist circumference (OR=1.65; 95% CI 0.87-3.14 for the highest tertile group compared to the lowest, P for trend=0.04) was significantly associated with breast cancer risk and only in Filipino women. The association with many other established risk factors, such as BMI, hormone use and physical activity, were in the expected direction but were not significant. Associations for family history of breast cancer and alcohol intake were not evident CONCLUSIONS: The results provide a basis for cancer prevention guidance for women in the Mariana Islands.

Island populations

BACKGROUND

Cancer disparities within and across populations provide insight into the influence of lifestyle, environment, and genetic factors on cancer risk.

METHODS

Guam cancer incidence and mortality were compared to that of Hawaii using data from their respective population-based, central cancer registries.

RESULTS

In 2009-2013, overall cancer incidence was substantially lower in Guam than in Hawaii for both sexes while overall cancer mortality was higher for Guam males. Cervical cancer incidence and prostate cancer mortality were higher in Guam. Both incidence and mortality were higher among Guam men for cancers of the lung & bronchus, liver & intrahepatic bile duct, and nasopharynx; Chamorro men were disproportionately affected by these cancers. Filipinos and Whites in Guam had lower overall cancer incidence compared to Filipinos and Whites in Hawaii. Although breast cancer incidence was significantly lower in Guam compared to Hawaii, women in Guam presented at younger ages and with rarer disease histologies such as inflammatory carcinoma were more prevalent. Guam patients were also diagnosed at younger ages for cancers of bladder, pancreas, colon & rectum, liver & intrahepatic bile duct, lung & bronchus, stomach, non-Hodgkin lymphoma, and leukemia.

CONCLUSION

Smoking, infectious agents, and betel nut chewing appear to be important contributors to the burden of cancer in Guam. Earlier onset of cancer in Guam suggests earlier age of exposure to key risk factors and/or a more aggressive pathogenesis. Contrasting cancer patterns within Guam and between Guam and Hawaii underscore the potential influence of genes, lifestyle, and environmental factors on cancer development and progression.

The efficacy of respondent-driven sampling for the health assessment of minority populations

BACKGROUND

Respondent driven sampling (RDS) is a relatively new network sampling technique typically employed for hard-to-reach populations. Like snowball sampling, initial respondents or "seeds" recruit additional respondents from their network of friends. Under certain assumptions, the method promises to produce a sample independent from the biases that may have been introduced by the non-random choice of "seeds." We conducted a survey on health communication in Guam's general population using the RDS method, the first survey that has utilized this methodology in Guam. It was conducted in hopes of identifying a cost-efficient non-probability sampling strategy that could generate reasonable population estimates for both minority and general populations.

METHODS

RDS data was collected in Guam in 2013 (n=511) and population estimates were compared with 2012 BRFSS data (n=2031) and the 2010 census data. The estimates were calculated using the unweighted RDS sample and the weighted sample using RDS inference methods and compared with known population characteristics.

RESULTS

The sample size was reached in 23days, providing evidence that the RDS method is a viable, cost-effective data collection method, which can provide reasonable population estimates. However, the results also suggest that the RDS inference methods used to reduce bias, based on self-reported estimates of network sizes, may not always work. Caution is needed when interpreting RDS study findings.

CONCLUSIONS

For a more diverse sample, data collection should not be conducted in just one location. Fewer questions about network estimates should be asked, and more careful consideration should be given to the kind of incentives offered to participants.

Epidemiology of areca (betel) nut use in the mariana islands: Findings from the University of Guam/University of Hawai`i cancer center partnership program

BACKGROUND

Areca (betel) nut is considered a Group 1 human carcinogen shown to be associated with other chronic diseases in addition to cancer. This paper describes the areca (betel) nut chewing trend in Guam, and health behaviors of chewers in Guam and Saipan.

METHODS

The areca (betel) nut module in the Guam Behavioral Risk Factor Surveillance Survey was used to calculate the 5-year (2011-2015) chewing trend. To assess the association between areca (betel) nut chewing and health risks in the Mariana Islands, a cross-section of 300 chewers, ≥18years old, were recruited from households in Guam and Saipan. Self-reported socio-demographics, oral health behaviors, chronic disease status, diet, and physical activity were collected. Anthropometry was measured. Only areca (betel) nut-specific and demographic information were collected from youth chewers in the household.

RESULTS

The 5-year areca (betel) nut chewing prevalence in Guam was 11% and increased among Non-Chamorros, primarily other Micronesians, from 2011 (7%) to 2015 (13%). In the household survey, most adult chewers (46%) preferred areca nut with betel leaf, slaked lime, and tobacco. Most youth chewers (48%) preferred areca nut only. Common adult chronic conditions included diabetes (14%), hypertension (26%), and obesity (58%).

CONCLUSION

The 5-year areca (betel) nut chewing prevalence in Guam is comparable to the world estimate (10-20%), though rising among Non-Chamorros. Adult and youth chewers may be at an increased risk for oral cancer. Adult chewers have an increased risk of other chronic health conditions. Cancer prevention and intervention strategies should incorporate all aspects of health.

Para I Famagu'on-Ta: Fruit and Vegetable Intake, Food Store Environment, and Childhood Overweight/Obesity in the Children's Healthy Living Program on Guam

This cross-sectional study examined the: (1) association between food store environment (FSE), fruit and vegetable (FV) availability and access, and prevalence of early childhood overweight/obesity (COWOB); and (2) influence of young child actual FV intake on the relationship between the FSE and early COWOB prevalence. Anthropometric and socio-demographic data of children (2 to 8 years; N=466) in baseline communities on Guam participating in the Children's Healthy Living (CHL) Program community trial were included. CDC year 2000 growth charts were used to calculate BMI z-scores and categories. FSE factors (fresh FV scores, store type) were assessed using the CX3 Food Availability and Marketing Survey amended for CHL. ArcGIS maps were constructed with geographic coordinates of participant residences and food stores to calculate food store scores within 1 mile of participant's residences. A sub-sample of participants (n = 355) had Food and Activity Log data to calculate FV and energy intakes. Bivariate correlations and logistic regression evaluated associations. Of 111 stores surveyed, 73% were small markets, 16% were convenience stores, and 11% were large grocery/supermarkets. Supermarkets/large grocery stores averaged the highest FV scores. Most participants did not meet FV intake recommendations while nearly half exceeded energy intake recommendations. Living near a small market was negatively correlated with BMI z-score (r = - 0.129, P < .05) while living near a convenience store was positively correlated with BMI z-score (r = 0.092, P < .05). Logistic regression analysis yielded non-significant associations. The high density of small markets may be an opportunity for FSE intervention but further investigation of Guam's FSE influence on health is needed.

Survey for selected pathogens in wild pigs (Sus scrofa) from Guam, Marianna Islands, USA

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Guam has high wild pig densities with risk of pathogen transmission to people and animals.

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Exposure to numerous pathogens was detected in contrast to surveys of domestic pigs.

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New reports of pseudorabies virus, PRRS virus, Brucella, and Leptospira in pigs on Guam.

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Highlights that domestic swine-wild pig interactions should be prevented.

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Precautions are needed when handling wild pigs to minimize the pathogen transmission.

Pigs (Sus scrofa) were introduced to Guam in the 1600’s and are now present in high densities throughout the island. Wild pigs are reservoirs for pathogens of concern to domestic animals and humans. Exposure to porcine parvovirus, transmissible gastroenteritis, and Leptospira interrogans has been documented in domestic swine but data from wild pigs are lacking. The close proximity of humans, domestic animals, and wild pigs, combined with the liberal hunting of wild pigs, results in frequent opportunities for pathogen transmission. From February–March 2015, blood, tissue and ectoparasite samples were collected from 47 wild pigs. Serologic testing found exposure to Brucella spp. (2%), Toxoplasma gondii (11%), porcine reproductive and respiratory syndrome (PRRS) virus (13%), porcine circovirus type 2 (36%), pseudorabies virus (64%), Actinobacillus pleuropneumoniae (93%), Lawsonia intracellularis (93%), and porcine parvovirus (94%). Eleven (24%) samples had low titers (1:100) to Leptospira interrogans serovars Bratislava (n = 6), Icterohaemorrhagiae (n = 6), Pomona (n = 2), and Hardjo (n = 1). Kidney samples from nine pigs with Leptospira antibodies were negative for Leptospira antigens. Numerous pigs had Metastrongylus lungworms and three had Stephanurus dentatus. Lice (Hematopinus suis) and ticks (Amblyomma breviscutatum) were also detected. No antibodies to Influenza A viruses were detected. In contrast to the previous domestic swine survey, we found evidence of numerous pathogens in wild pigs including new reports of pseudorabies virus, PRRS virus, Brucella, and Leptospira in pigs on Guam. These findings highlight that domestic swine-wild pig interactions should be prevented and precautions are needed when handling wild pigs to minimize the risk of pathogen transmission.

Views From the Pacific--Military Base Hospital Libraries in Hawaii and Guam

Hospital libraries serving military bases offer a different perspective on library services. Two libraries located on islands in the Pacific Ocean provide services to active duty service men and women, including those deployed to other regions of the world. In addition, these hospital libraries serve service members' families living on the base, and often citizens from the surrounding communities.

Migrant encounters in the clinic: Bureaucratic, biomedical, and community influences on patient interactions with front-line workers

Ethnographic research on the clinical encounter has focused almost exclusively on what happens in exam rooms-particularly patient-provider interactions-leaving much to be understood about other actors within the clinic. As part of a larger ethnographic study examining the impact of colonialism, transnational migration, discrimination, and gender relations on Chuukese migrant women's reproductive and sexual health outcomes in Guam, I conducted eight months of participant observation in three publicly funded health clinics, 24 interviews with health care workers, and 15 life-history interviews with Chuukese women between September 2012 and February 2014. Findings demonstrated differential treatment of Chuukese patients by front-line workers (FLWs), who engaged in "boundary work" with these patients. Further, care varied by clinic space and the actors in that space. This differential treatment and variation in care impacted Chuukese women's access to and experiences with health care in Guam. Utilizing the concept of "deservingness," this analysis unpacks how FLWs, like Lipsky's "street-level bureaucrats," are influenced by bureaucratic, biomedical, and community hierarchies, all contributing to differential patient treatment. This study concludes by calling for more integrated analyses of clinical environments which utilize Lipsky's concept to include community narratives of "deservingness" and incorporate the influence of clinic and community stratification.

Disparities in Infant Mortality Due to Congenital Anomalies on Guam

In the 1970's and 1980's, there were large inter-village disparities in infant mortality due to congenital anomalies on Guam. A village-level analysis was conducted to determine if these disparities can be explained by behavioral (ie, median age of village females, village fertility ratio), structural (ie, population density, persons per household, single mother households per village, married females per village), and environmental (ie, living in a village where Agent Orange (AO) spraying was conducted) factors. Village-level data for live births and infant mortality due to congenital anomalies (1970-1989) was collected from Guam's Office of Vital Statistics. Data on median age of village females, village fertility ratio, population density, persons per household, single mother households, and married females were obtained from the 1980 US Census. Estimates of village-level AO use were provided through personal communications, and villages were dichotomized into AO and non-AO spray areas. Village location was classified by usual residence of the mother. Linear regression was used to determine associations between infant mortality due to congenital anomalies and the behavioral, structural, and environmental factors. The association between AO spray area and infant mortality due to congenital anomalies was statistically significant under univariable (B [95%CI] = 1.88 [0.64,3.11], P = .005) and multivariable conditions (B [95%CI] = 2.02 [0.08,3.96], P = .042). These results suggest that infants born to mothers whose usual residence was in an AO spray area on Guam are at an increased risk of mortality due to congenital anomalies. Further studies using individual-level data are needed to validate these results.