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The percentages of retention in care and viral suppression among persons living with HIV (PLWH) in the United States from 2015 to 2018 were far below the 2020 national goals. This study aims to examine disparities in retention in care and viral suppression. The study population included PLWH diagnosed through 2016, residing in Hawaii at year-end 2016 and 2017, and who were in care in 2017 defined as having ≥1 CD4/viral load tests in 2017. Care providers were categorized as "very frequent" (≥50 patients), "frequent" (25–49 patients), "occasional" (10–24 patients), and "infrequent" (<10 patients). Among the 1752 patients included, 28.0% were not retained in care in 2017 (i.e., <2 CD4/VL tests performed at least 3 months apart), of whom 89.2% had only a single viral load test. Patients receiving care from the "infrequent" group of providers were less likely to be retained in care (adjusted odds ratio (aOR) = 0.48; 95% CI = 0.33, 0.69) or virally suppressed (aOR = 0.39; 95% CI = 0.24, 0.63), than patients receiving care from the "very frequent" group of providers. Percentages of three-year (2016–2018) in care and viral suppression were lowest among patients receiving care from "infrequent" care providers. Patients <45 years old were less likely to be retained in care (aOR = 0.53; 95% CI = 0.41, 0.68) or be virally suppressed (aOR = 0.59; 95% CI = 0.40, 0.86) than those 45 years or older. Patients of multiple races were less likely to be virally suppressed than whites (aOR = 0.38, 95% CI = 0.23, 0.64). Establishing a long-term relationship with an experienced HIV provider appears beneficial to achieve sustainable viral suppression and provision of uninterrupted HIV medical care. [ABSTRACT FROM AUTHOR]

Hawai'i has one of the highest rates of liver cancer in the United States. This is in large part due to undiagnosed chronic hepatitis B (CHB) infection among foreign-born Asian and Pacific Islanders (APIs). In order to estimate the prevalence of CHB infection among foreign-born APIs in Hawai'i, the Hawai'i State Department of Health conducted a cross-sectional study from August 2013 through August 2015 of patients of a federally qualified health center serving the largest population of medically underserved APIs in the state. Among 1261 patients surveyed, the prevalence of CHB infection (based on HBsAg seropositivity) was 5.6% (71/1259). No significant differences were detected by place of birth, age, or gender; however, the adjusted prevalence ratio of CHB infection was 6.0 times higher among persons reporting household contact with hepatitis B virus compared with those without such contact. Our findings underscore the need for targeted screening of at-risk individuals and their household contacts. [ABSTRACT FROM AUTHOR]

Objectives. To examine racial/ethnic disparities in Hawaii in stage 3 classification at HIV diagnosis and trends in such disparities from 2010 through 2016. Methods. We analyzed data including patients' demographic information, behavioral risk factors, residential county at HIV diagnosis, and type of facility where HIV was diagnosed. Multivariable logistic regression modeling was used to examine racial/ethnic disparities in late-stage diagnoses after adjustment for known or possible confounders. Results. About 30% of HIV diagnoses were classified as late-stage (stage 3) diagnoses, and there were significant racial/ethnic disparities in stage 3 classification at diagnosis. Relative to Whites, the odds of being diagnosed at stage 3 were 3.7 times higher among Native Hawaiians and other Pacific Islanders (NHPIs; odds ratio [OR] = 3.69; 95% confidence interval [CI] = 1.89, 7.22) and more than twice as high among Asians (OR = 2.46; 95% CI = 1.16, 5.20). Older age and being diagnosed in an inpatient setting were associated with stage 3 classification. Conclusions. Targeted preventive services need to be strengthened for Asians and NHPIs in Hawaii. [ABSTRACT FROM AUTHOR]

Background: The Community Health Outreach Work to Prevent AIDS (CHOW) Project is the first and longest-standing statewide integrated and funded needle and syringe exchange program (SEP) in the US. Initiated on O'ahu in 1990, CHOW expanded statewide in 1993. The purpose of this study is to estimate the prevalences of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infection, and to characterize risk behaviors associated with infection among clients of a long-standing SEP through the analysis of the 2012 CHOW evaluation data.Methods: A cross-sectional sample of 130 CHOW Project clients was selected from January 1, 2012 through December 31, 2012. Questionnaires captured self-reported exposure information. HIV and HCV antibodies were detected via rapid, point-of-care FDA-approved tests. Log-binomial regressions were used to estimate prevalence proportion ratios (PPRs). A piecewise linear log-binomial regression model containing 1 spline knot was used to fit the age-HCV relationship.Results: The estimated seroprevalence of HCV was 67.7% (95% confidence interval [CI]=59.5-75.8%). HIV seroprevalence was 2.3% (95% CI=0-4.9%). Anti-HCV prevalence demonstrated age-specific patterns, ranging from 31.6% through 90.9% in people who inject drugs (PWID) <30 to ≥60 years respectively. Age (continuous/year) prior to spline knot at 51.5 years (adjusted PPR [APPR]=1.03; 95% CI=1.02-1.05) and months exchanging syringes (quartiles) (APPR=1.92; 95% CI=1.3-3.29) were independently associated with anti-HCV prevalence.Conclusion: In Hawai'i, HCV prevalence among PWID is hyperendemic demonstrating age- and SEP duration-specific trends. Relatively low HIV prevalence compared with HCV prevalence reflects differences in transmissibility of these 2 blood-borne pathogens and suggests much greater efficacy of SEP for HIV prevention. [ABSTRACT FROM AUTHOR]

Background: Depression and anxiety are common conditions among pregnant and postpartum women, but population-based information is lacking on treatments and help-seeking behaviors. Purpose: This study described the prevalence of depression, anxiety, pharmaceutical treatment, and help-seeking behaviors among a multiethnic population of women with recent live births in Hawaii. Method: Hawaii Pregnancy Risk Assessment Monitoring System data from 4735 respondents were weighted to be representative of all pregnancies resulting in live births in Hawaii in 2009-2011 and were used to estimate the prevalence of several indicators related to anxiety and depression before, during, and after pregnancy among women with recent live births. Results: Of Hawaii women with live births in 2009-2011, 7.3 % reported visiting a healthcare worker to be checked or treated for depression or anxiety in the year before their most recent pregnancy, 4.9 % reported having depression in the 3 months before pregnancy, 5.9 % reported having anxiety in the same period, 9.1 % screened positive for postpartum depression, and 6.9 % reported asking a doctor, nurse, or other healthcare worker for help for anxiety postpartum. The prevalence of antianxiety and antidepressant prescription drug use was 2.3 % in the month before pregnancy and 1.4 % during pregnancy. Hawaii had lower prevalence of pre-pregnancy depression, anxiety, and depression/anxiety health visits than other US states. Pre-pregnancy depression and anxiety and postpartum anxiety help-seeking behaviors differed significantly by race/ethnicity. Conclusion: Depression and anxiety are common among pregnant and postpartum women in Hawaii. More research could better inform heath care professionals and patients of the treatment options available and their potential risks and benefits. [ABSTRACT FROM AUTHOR]

Background Pelvic inflammatory disease (PID) is a notifiable disease in Hawaii with legal implications for noncompliance. A previous study comparing PID diagnoses in Hawaii's hospitals and state surveillance data confirmed underreporting in Hawaii. Reasons for noncompliance and underreporting are not well understood. Methods All licensed primary care physicians in Hawaii were mailed a survey addressing PID diagnosis and reporting attitudes and practices. Hierarchical logistic regression was used to determine if physician characteristics, PID knowledge, or attitudes related to the diagnosis or reporting of PID, increased the odds of diagnosing and reporting PID. Results Among survey respondents (486 of 1,062; response rate of 45.8%), 104 (21.4%) had diagnosed PID. The PID reporting rate was 55.8% (58 of 104). The majority of physicians who diagnosed PID reported that PID reporting was time consuming. In hierarchical regression, obstetrician/gynecologists and family practitioners had the highest odds of diagnosing PID and internists had the lowest odds of reporting PID, those 15 years or longer since residency were less likely to report PID than those fewer than 15 years since residency, and increased PID diagnosing and reporting knowledge increased the odds of PID reporting by 1.63 times. Conclusion Our findings suggest the need for training of all physicians on reportable diagnoses on a regular basis. There is a need to simplify the reporting process, because the time burden of reporting may present a modifiable barrier to reporting. Increased PID-related communication between local health departments and physicians is essential, and physicians should be provided technical assistance with reporting. [ABSTRACT FROM AUTHOR]

We sought to determine the prevalence of HCV infection and identify factors associated with HCV infection among clients presenting to community-based health settings in Hawai'i from 2010-2013. An earlier report on this study population covered the period from December 2002 through May 2010. Since 2010, the HCV screening inclusion criteria have been relaxed, and the program has greatly expanded. Clients from 26 community-based sites were administered questionnaires, and were screened for HCV antibodies from January 2010 through April 2013 (N = 8,588). Univariate and multivariate logistic regression analyses were performed. HCV antibody prevalence was 5.9% compared with 11.9% from 2002-2010. Persons aged 45-65 years had the highest HCV antibody prevalence (8.4%) compared with all other age groups. Significant independent variables associated with HCV antibody prevalence were injection drug use, blood transfusion before July 1992, and having an HCV-infected sexual partner. While characteristics associated with HCV infection remained essentially unchanged from those identified in the earlier analysis, the expansion of screening sites and less restrictive inclusion criteria led to a much larger study population and a concurrent decrease in overall HCV antibody prevalence. However, while the highest age-specific prevalence remained the same for both screening periods, the prevalence among younger persons (< 30 years old) doubled (from 2.4% to 4.7%). By expanding the HCV screening program and relaxing the inclusion criteria, a greater number of HCV-infected persons and a greater proportion of younger persons with HCV infection were identified while still maintaining a focus on at-risk individuals. [ABSTRACT FROM AUTHOR]

During 2016, eight Neisseria gonorrhoeae isolates from 7 patients in Hawaii were resistant to azithromycin; 5 had decreased in vitro susceptibility to ceftriaxone. Genomic analysis demonstrated a distinct phylogenetic clade when compared with local contemporary strains. Continued evolution and widespread transmission of these strains might challenge the effectiveness of current therapeutic options. [ABSTRACT FROM AUTHOR]

Objectives. We sought to determine the prevalence of HCV infection and identify risk factors associated with HCV infection among at-risk clients presenting to community-based health settings in Hawaii. Methods. Clients from 23 community-based sites were administered risk factor questionnaires and screened for HCV antibodies from December 2002 through May 2010. We performed univariate and multivariate logistic regression analyses. Results. Of 3306 participants included in the analysis, 390 (11.8%) tested antibody positive for HCV. Highest HCV antibody prevalence (17.0%) was in persons 45 to 64 years old compared with all other age groups. Significant independent risk factors were current or prior injection drug use (P< .001), blood transfusion prior to July 1992 (P= .002), and having an HCV-infected sex partner (P=.03). Stratification by gender revealed sexual exposure to be significant for males (P=.001). Conclusions. Despite Hawaii's ethnic diversity, high hepatocellular carcinoma incidence, and a statewide syringe exchange program in place since the early 1990s, our HCV prevalence and risk factor findings are remarkably consistent with those reported from the mainland United States. Hence, effective interventions identified from US mainland population studies should be generalizableto Hawaii. [ABSTRACT FROM AUTHOR]

Since the early 1990s, national rates of methicillin-resistant Staphylococcus aureus (MRSA) infections have increased dramatically. Initially identiied in health care settings, community-acquired MRSA is now a major public health concern. With Hawai'i's expanding S. aureus and MRSA epidemic closely approximating the national trend in inpatient and outpatient settings, a high level of knowledge and awareness among health care workers is essential to successfully control this evolving epidemic. Health care and related workers were surveyed to assess their knowledge and perceptions about staphylococcal and MRSA infections. Knowledge was estimated by demonstrated ability to correctly identify risk factors including diabetes and obesity, as well as to demonstrate awareness of a growing staphylococcal and MRSA epidemic. Perceptions were estimated by level of concern of antibiotic resistance as well as of the severity of the staphylococcal and MRSA epidemic. Variations in knowledge and perception concerning basic principles associated with S. aureus infections as well as characteristics of the evolving S. aureus and MRSA epidemic were observed among various occupations (advance clinical practitioners, nurses, public health professionals, athletic trainers, and non-medical workers) as well as work locations (hospital, community, and non-clinical community). Overall, health care and related workers in community settings demonstrated disparities in knowledge regarding S. aureus and MRSA infections. They were also more likely to misperceive this growing threat. These indings provide support for focused educational interventions targeting community health care and related workers to improve awareness of staphylococcal infections in order to successfully address and combat this evolving epidemic. [ABSTRACT FROM AUTHOR]

The US Centers for Disease Control and Prevention recently updated its recommendations for treating sexually transmitted diseases (STDs). In this review we highlight new treatment recommendations for mitigating the increasing prevalence of antibiotic-resistant Neisseria gonorrhoeae, the emergence of azithromycin-resistant Treponema pallidum, and treatment options for bacterial vaginosis and venereal warts. We also cover epidemiologic trends for common STDs in Hawai'i. [ABSTRACT FROM AUTHOR]

Hawaii currently ranks first among states for chlamydia screening of young women based on recent Healthcare Effectiveness Data and Information Set (HEDIS) measures and has consistently ranked in the top ten states in the US for annual reported chlamydia rates since 2002. A statewide provider survey was conducted in October 2007 and March 2008 to assess chlamydia screening practices and beliefs and identify potential barriers to screening. The overall reported screening rate for 15-19 year old females was 66.9% with significant differences by practice specialty (obstetrician/gynecologists were more likely to screen than family practitioners or pediatricians) and practice setting (higher rates of screening in non-private practice settings). Providers who were unaware of health plan reimbursement for screening and those who targeted screening only for clients perceived to be at 'high risk' were significantly less likely to routinely provide screening. The Hawaii State Department of Health is currently working in consort with health care providers and the state's dominant health insurance carriers to address these issues through targeted provider educational interventions. [ABSTRACT FROM AUTHOR]

Although infrequently diagnosed in the United States, leptospirosis is a notable reemerging infectious disease throughout developing countries. Until 1995, when the disease was eliminated from the US list of nationally notifiable diseases, Hawaii led the nation in reported annual incidence rates. Leptospirosis remains a notifiable disease in Hawaii. To ascertain the status of leptospirosis in Hawaii since the most recent US report in 2002, we reviewed 1999-2008 data obtained from case investigation reports by the Hawaii State Department of Health. Of the 345 case reports related to in-state exposures, 198 (57%) were laboratory confirmed. Our findings indicate a change in seasonal disease occurrence from summer to winter and in the infective serogroup from Icterohemorrhagiae to Australis. Also, during the past 20 years, recreational exposures have plateaued, while occupational exposures have increased. Ongoing surveillance is needed to clarify and track the dynamic epidemiology of this widespread zoonosis. [ABSTRACT FROM AUTHOR]

A recent case investigation of secondary syphilis in a 27-year-old heterosexual Micronesian male and his 19-year-old chlamydia and syphilis co-infected female partner, conducted by the Hawaii State Department of Health, June to August 2007, identified a cluster of 13 case-patients with undiagnosed syphilis, chlamydia, and gonorrhea. The social network of Micronesians uncovered was characterized by having transient accommodations but a central gathering place. The critical factor in gaining access to this network was the establishment of a trusting relationship with a key social network member. Field interviews and the application of field diagnostic techniques helped to identify case-patients who otherwise would not have presented to a traditional office or clinic setting. Micronesians in Hawaii represent an at-risk population for adverse health indices including sexually transmitted diseases, based on their socioeconomic status. [ABSTRACT FROM AUTHOR]

The purpose of this study is to assess the objective knowledge of mental health professionals in Hawaii related to evidence-based early psychological interventions for victims of mass trauma as well as their perceived response readiness to a bio terrorism associated event. During June and July 2004 an anonymous survey was mailed as many as three times to a random sample of licensed psychologists and social workers residing in Hawaii (n = 273). The response rate for deliverable surveys was 68 percent (176 of 257). Only 10 percent of respondents reported prior bio terrorism preparedness training. Less than 50 percent felt able to identify and manage populations exhibiting the normal range of stress reactions to a bioterrorist event, and only 19 percent felt able to distinguish psychological illness from the organic sequelae of a bioterrorist event. However, 75 percent expressed willingness to provide assistance in the state's bio terrorism response and control efforts. Respondents who were retired or inactive scored significantly lower than their actively employed peers on the objective knowledge questions. These finding indicate that more attention needs to be focused on bio terrorism preparedness training of mental health professionals to improve their ability to respond effectively. [ABSTRACT FROM AUTHOR]

Leptospirosis is a zoonotic infectious disease of global significance. Political, economic, demographic, ecologic, and other anthropogenically driven environmental changes have fueled the reemergence of this disease in industrialized and developing countries, and in both urban and rural settings. We argue that conventional disciplinary, even interdisciplinary, research methods are not sufficient to elucidate the complex mechanisms and causal relationships among the myriad factors responsible for infectious disease emergence. To address the significant gaps in the field of leptospirosis, an integrated research agenda is needed to guide successful public health remediation of the disease. Based on both working group analysis of literature and newly obtained information, we describe cross-disciplinary collaborative approaches that allow a novel approach to understand leptospirosis emergence with regard to mountain-to-sea ecosystems in Hawai‘i and other region-specific ecosystems. Leptospirosis research is a model for how complementary disciplines in the social, cultural, ecological, and biomedical sciences can optimally interact towards a higher understanding of emerging infectious diseases. [ABSTRACT FROM AUTHOR]

Methamphetamine abuse is epidemic in Hawaii, but the extent of use among pregnant women is unknown. We sought to define the prevalence of use during pregnancy. We conducted a cross-sectional study of consecutive births between November and December 1999, and determined that the prevalence of drug metabolites in meconium were fatty acid ethyl esters: 72 (17.1%); cotinine: 33 (7.7%); opiates: 4 (0.9%); delta-9 tetrahydrocannabinal: 1 (0.2%); and methamphetamine: 3 (0.7%). Including three positives discovered solely through forensic testing, the overall prevalence of methamphetamine exposure during pregnancy was 1.4% (6/443). The prevalence of methamphetamine was Iow compared to the prevalence of fatty acid ethyl esters, reportedly indicative of ethanol exposure, and cotinine, a tobacco metabolite. In Hawaii, more attention should be directed towards alcohol and tobacco use during pregnancy. [ABSTRACT FROM AUTHOR]

Summary Laboratory confirmation of leptospirosis is usually accomplished serologically, without isolates, using the microscopic agglutination test (MAT). However, optimal performance of the MAT is dependent on the knowledge of enzootic serogroups and serovars so that an appropriate MAT antigen testing battery can be established. Infecting leptospiral serogroups can be identified serologically without isolates, using the MAT, or by serogrouping of isolates, but little information is available regarding the correlation between these methods. The identification of infecting serogroups for 53 culture-confirmed leptospirosis cases, diagnosed in Hawaii between 1979 and 1998, using serology and culture isolates were compared. The overall agreement between the two methods was good (κ = 0.71, 95% CI: 0.56, 0.86). However, the agreement varied between serogroups from 0 to 100%. In establishing the prevalence of serogroups, results obtained via MAT serology (in the absence of serogrouped isolates) should be considered presumptive rather than definitive. [ABSTRACT FROM AUTHOR]

Presents a study that assessed the clinical presentation and treatment of confirmed leptospirosis cases in Hawaii from 1974-1998. Reason for misdiagnosis of the disease; Regions in which the disease is common; Information on how the disease is contacted by humans.

Hawaii is one of only 19 states for which pelvic inflammatory disease (PID) is a mandated notifiable disease. In order to assess the completeness of PID reporting, we compared the number of hospitalized PID cases in the state of Hawaii with the total number of PID cases reported to the Hawaii State Department of Health surveillance system from 2007 through 2010. While 828 unique PID cases were diagnosed in Hawaii hospitals, only 240 unique PID cases were reported through the state's surveillance system. Severe PID underreporting was seen despite mandatory reporting laws. [ABSTRACT FROM AUTHOR]

Currently, the carriage rate for Community-Acquired Methicillin Resistant Staphylococcus aureus (CAMRSA) is unknown in Hawai'i. This survey focuses on a healthy population of 95 college students and 5 faculty who completed a survey related to possible risk factors for colonization of Staphylococcus aureus and were sampled for S. aureus from their anterior nares. Thirty-three (33%) subjects were carrying Staphylococcus aureus and of those, 3 (3%) carried MRSA. There was no significant association between Staphylococcus aureus carriage and ethnicity, gender, exposure to seawater, prior Staphylococcus aureus infections, recent antibiotic use, or pets. Additional testing of a larger group of healthy individuals would be beneficial in assessing factors associated with CA-MRSA and Methicillin-susceptible Staphylococcus aureus (MSSA ) carriage in Hawai'i. [ABSTRACT FROM AUTHOR]

During the summer of 1987, a common source waterborne outbreak of leptospirosis occurred on the island of Kauai in the state of Hawaii. Eight leptospirosis cases were identified using the microscopic agglutination test. Methodologic weaknesses in this technique were responsible for the initial missed diagnosis on six of the eight cases. All cases had repeated exposure to the Waimea River. A wide array of animal reservoirs and optimal water conditions may have been factors in this outbreak. [ABSTRACT FROM AUTHOR]

One hundred and six dozen eggs, representing 12 brands, were purchased from Oahu supermarkets and cultured for Salmonella using standard FDA (Food and Drug Administration) microbiological techniques. Two enrichment incubation temperatures were used to improve culture sensitivity. Ten cartons (9.4 pet cent) of the 106 dozen samples had shells positive for Salmonella. Seven of the 10 were traced to a single egg processor. Inspection of the facility led to the discovery of malfunctioning equipment used in the egg washing and sanitation process. [ABSTRACT FROM AUTHOR]

Abstract: The Hawaii State Department of Health's Chlamydia Network Project screened 272 asymptomatic females for chlamydia; 20 (7.4 per ¢) were found to be positive. When interviewed, 75 per ¢ (15/20) of the cases gave information such that their sexual partner(s) could be located. Ninety per ¢ (14/16) of the locatable partners were brought to examination within seven days. Keys to success were the training of family planning clinic staff in STD (sexually transmitted disease) control methods, and close intraagency cooperation. [ABSTRACT FROM AUTHOR]

Introduction: Since the early 1990s, national rates of methicillin-resistant Staphylococcus aureus (MRSA) infections have increased dramatically. Initially identified in health care settings, community-acquired MRSA is now a major public health concern. With Hawai'i's strikingly high incidence and prevalence of MRSA infections, a high level of knowledge and awareness among health care workers is essential to successfully controlling this evolving epidemic. Methods: Health care and related workers were surveyed to assess their knowledge and perceptions about staphylococcal and MRSA infections. Knowledge was estimated by demonstrated ability to correctly identify risk factors including diabetes, obesity, pets, and seawater exposure as well as understanding the seriousness of antibiotic resistance. Perceptions were estimated by demonstrated awareness of the severity and elevated incidence and prevalence of S. aureus and MRSA infections. Results: This study identified that occupation (advance clinical practitioner, nurse, public health professional, athletic trainers, and non-medical workers) as well as work location (community vs hospital) influence knowledge and perceptions regarding the epidemiology, severity, and risk factors of S. aureus and MRSA infections. Additionally, despite a well-documented global crisis with antibiotic resistance, Hawai'i's community health care workers were less inclined to correctly identify the threat of antibiotic resistance as compared to their hospital-based colleagues. Conclusion: Trends were observed in knowledge and perceptions with level of medical education. Differences were also noted according to work location. Overall, health care and related workers in the community were less likely to understand basic principles associated with S. aureus infections as well as misperceive this imminent threat. These findings provide compelling evidence for focused educational interventions targeting community health care and related workers to improve awareness of staphylococcal infections in order to successfully address and combat this emerging epidemic. [ABSTRACT FROM AUTHOR]

The objective of this study was to estimate the prevalence of chronic hepatitis B infection in foreign-born Asians and Pacific Islanders at Kalihi-Palama Health Center in Honolulu, Hawai'i, and to assess the association between both chronic and resolved hepatitis B infection and risk factors such as household exposure to hepatitis B virus and geographic location of birthplace. The study involved cross-sectional data from 997 participants who accessed medical services at Kalihi-Palama Health Center between September 2015 and July 2020. The prevalence of chronic hepatitis B was 10.7%. On multivariable logistic regression analysis, the adjusted prevalence odds ratio of chronic hepatitis B infection was 3.3 times greater (95% confidence interval: 1.1, 9.2) for those who reported household contact with a person with hepatitis B infection than those who reported no such contact. No association was found with place of birth in this study population. Age was a significant predictor of chronic hepatitis B, with participants between 35-44 years of age having the highest prevalence. Age was also a significant predictor of resolved hepatitis B infection, with participants 65 years of age or older having the highest prevalence. These findings emphasize the need for targeted screening and appropriate follow-up-including vaccination or treatment-in this at-risk population., Competing Interests: None of the authors identify a conflict of interest., (©Copyright 2024 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Objective: This study describes HIV infection and associated risk factors among males diagnosed with syphilis in Hawaii., Methods: Hawaii sexually transmitted infection (STI) registry records of males diagnosed with syphilis, 2014-2019, were crossmatched with Hawaii HIV surveillance registry records through 2020 using CDC's Registry Plus Link Plus software. HIV status from the STI registry was validated by matching results. Logistic regression was used to examine demographic and behavioral factors associated with HIV infection., Results: Among the 947 male syphilis cases, 257 (27.1%) had both syphilis and HIV infections. Dual infection rates were higher in earlier years (39.5% in 2015), among older patients (41.6% among persons ≥45 years old), males who have sex with males (MSM, 36.6%), and cases with repeated syphilis events (59.5%). The overall agreement on HIV status between the STI registry and matching results was 95.7%., Conclusions: Over a quarter (27.1%) of male syphilis cases were living with HIV. HIV infection rates were higher among older patients, MSM, and males with repeated syphilis events. Periodic matching between STI and HIV registries provides opportunities for quality control to both registries and opportunities to identify patients not linked to HIV care or who have fallen out of HIV care.

Introduction: This paper explores two objectives: (1) effectiveness of interprofessional education facilitators utilizing distance technology to facilitate and debrief an interprofessional exercise with students located on the islands Oahu and Hawai'i Island (Hilo), and (2) impact of technology on the simulation experience for facilitators and students., Methods: Four disciplines participated in an interprofessional hospital discharge exercise for the same geriatric patient case. Two questions administered to facilitators and students after each session focused on: (1) satisfaction with the students' ability to work through the simulation, and (2) satisfaction with the use of distance technology., Results: Results showed no significant differences when comparing students to facilitators for the students' ability to work through the simulation. Students gave significantly lower satisfaction scores with distance technology than faculty. There were no significant differences in scores among disciplines between either facilitators or students. Pharmacy distance students had significantly lower scores for satisfaction with the simulation exercise and for the role of distance technology compared to other students. Qualitative analyses showed trend improvements over five semesters in four technology areas; volume, noise, difficulty with clarity/understanding, and seating location/placement issues for the on-site group, but only significant improvement with clarity/understanding in the distance group., Conclusions: Interprofessional simulation exercises can be successfully facilitated from both on-site and distance site without compromising students' ability to work through the exercise. Satisfaction with distance technology was lower for distance student groups., (Copyright © 2020. Published by Elsevier Inc.)

Gonorrhea is the second most common nationally notifiable infectious disease in the United States. Rates have been increasing nationally as have antibiotic-resistant isolates. Both the Centers for Disease Control and Prevention and the World Health Organization have recognized antibiotic-resistant Neisseria gonorrhoeae as a major public health threat and have warned of the emerging threat of "untreatable" gonorrhea. Hawai'i has been on the front lines nationally for gonococcal antimicrobial susceptibility surveillance due to its long-standing, statewide gonococcal isolate surveillance program coupled with antibiotic susceptibility testing of all isolates, and Hawai'i's geographic location between Asia where drug-resistant strains originate, and the continental United States. This article highlights emerging trends in and current status of antibiotic resistant Neisseria gonorrhoeae from a national and Hawai'i perspective., (©Copyright 2020 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Background Previously, Kuakini Honolulu Heart Program researchers reported that occupational exposure to pesticides was significantly associated with total mortality. The current study examines occupational exposure to pesticides in relation to incident cardiovascular disease, defined as coronary heart disease or cerebrovascular accident. Methods and Results With the Occupational Safety Health Administration exposure scale used as an estimate of exposure, statistical analyses were performed on a cohort of 7557 Japanese-American men from the Kuakini Honolulu Heart Program. Hazard ratios for cardiovascular disease incidence were calculated for various levels of pesticide exposure using Cox proportional hazards models. In the first 10 years of follow-up, a positive association was observed between age-adjusted cardiovascular disease incidence and high levels of pesticide exposure (hazard ratio=1.46, 95% CI=1.10-1.95, P =0.009). This relationship remained significant after adjustment for other cardiovascular disease risk factors (hazard ratio=1.42, 95% CI=1.05-1.92, P =0.021). No significant association for coronary heart disease or cerebrovascular accident incidence with pesticide exposure was observed when examined separately, possibly due to a smaller number of events. Conclusions These findings suggest that occupational exposure to pesticides may play a role in the development of cardiovascular diseases. The results are novel, as the association between occupational exposure to pesticides and cardiovascular disease incidence has not been examined previously in this unique cohort.

Pelvic inflammatory disease is a state-mandated notifiable disease in Hawai'i. A survey assessing pelvic inflammatory disease (PID) reporting to the Hawai'i Department of Health (HDOH) PID surveillance system, was administered to physicians in Hawai'i in April 2012. To measure the accuracy of self-disclosed PID reporting, data from the survey were compared to HDOH PID surveillance system case reports. Concordance between the two data sources was assessed using Cohen's kappa statistic. We first linked data by physician name. An adjusted kappa was also calculated to minimize prevalence and bias effects. A second analysis linked data according to physician name or practice setting. In the name-based analysis, the HDOH PID surveillance database successfully matched only ten of 118 physicians (8.5%) who self-disclosed reporting a PID case. Only "slight agreement" (k= 0.09, 95% confidence interval [CI]: 0.02-0.16) was demonstrated between the two databases. The prevalence-adjusted, bias-adjusted kappa demonstrated "moderate agreement" (κ=0.53, 95% CI: 0.45-0.60). In the second (name or practice-based setting) analysis, 77 physicians with linkages were found in the HDOH surveillance database, reflecting "moderate agreement" (κ=0.52, 95% CI 0.43, 0.61). Our findings provide evidence that individual physicians are submerging their case reports into group practice/HMO aggregate reports and not reporting individually as legally mandated and hence are compromising PID surveillance quality., Competing Interests: None of the authors identify a conflict of interest.

Background: The Centers for Disease Control and Prevention (CDC) currently recommends dual therapy with ceftriaxone and azithromycin for gonorrhea to ensure effective treatment and slow emergence of antimicrobial resistance. Since 2013, the prevalence of reduced azithromycin susceptibility increased in the United States; however, these strains were highly susceptible to cephalosporins. We identified a cluster of Neisseria gonorrhoeae isolates with high-level azithromycin resistance, several of which also demonstrated decreased ceftriaxone susceptibility., Methods: Eight N. gonorrhoeae isolates collected from 7 patients on Oahu, Hawaii, seen 21 April 2016 through 10 May 2016 underwent routine Etest antimicrobial susceptibility testing by the Hawaii Department of Health. All demonstrated elevated azithromycin minimum inhibitory concentrations (MICs) >256 μg/mL and elevated ceftriaxone MICs (≥0.125 μg/mL). Isolates were sent to the University of Washington and CDC for confirmatory agar dilution testing; sequence data were sent to CDC for analysis. All patients were interviewed and treated, and when possible, partners were interviewed, tested, and treated., Results: All isolates had azithromycin MICs >16 µg/mL and 5 had ceftriaxone MICs = 0.125 µg/mL by agar dilution. All isolates were β-lactamase positive and were resistant to penicillin, tetracycline, and ciprofloxacin. Genomic analysis revealed genetic relatedness. No patients reported recent travel or antibiotic use, and no male patients reported male sex partners. All patients were successfully treated., Conclusions: This cluster of genetically related gonococcal isolates with decreased ceftriaxone susceptibility and high-level azithromycin resistance may bring the threat of treatment failure in the United States with the current recommended dual therapy one step closer., (© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Among gonococcal isolates examined at the Hawaii State Laboratory Division from 2003 to 2011, the prevalence of elevated cefixime minimum inhibitory concentrations (MICs; ≥0.064 μg/mL) and elevated cefpodoxime MICs (≥0.19 μg/mL) increased over time. In contrast, few isolates exhibited elevated ceftriaxone MICs (≥0.094 μg/mL), and the prevalence of elevated ceftriaxone MICs did not change.

We describe the geographic distribution and variation in host-pathogen specificity for Leptospira-infected small mammals collected concurrently from three Hawaiian Islands over a period of 14 years: 1990-2003. Four serogroups (Icterohaemorrhagiae, Ballum, Sejroe, and Australis) were identified from the 15,171 animals tested. Serogroup prevalence differed across host species and islands (P < 0.0001 for each), but not across years. The host associations and biogeographic patterns of Leptospira in Hawaii indicate a pathogen community shaped by ecological factors.

We report on the first Neisseria gonorrhoeae isolate in the United States identified with high-level resistance to azithromycin. This report discusses the epidemiologic case investigation, the molecular studies of resistance-associated mutations and N. gonorrhoeae multiantigen sequence typing, and challenges posed by emerging gonococcal antimicrobial resistance.

An adult male presented to the Hawaii Health Department with a purulent urethral discharge. Urethral Gram stain examination led to a presumptive gonorrhea diagnosis even though his sexual history was nonsupportive. Culture results identified Neisseria meningitidis. This case report highlights the clinical similarities and differing epidemiology of these Neisseria urethritides.

During the 10-year period from 1997 through 2006, the reported mean annual incidence rate of leptospirosis in the state of Hawaii was 3.3/100,000 with a range of 22-60 infections reported each year. Because the clinical presentation is highly variable, however, leptospirosis illness is challenging to recognize and may be underdiagnosed. To assess whether the incidence may be substantially higher than reported figures indicate, we retrospectively studied the prevalence of anti-Leptospira IgM antibodies among specimens obtained over a 12-month period (May 2001 to April 2002) from patients presenting with febrile illness during a dengue fever outbreak in Hawaii. Of 1206 patients testing negative or indeterminate for dengue, 54 (4.5%; 95% confidence interval: 3.3%-5.7%) were positive for anti-Leptospira IgM antibodies using a commercially available dipstick enzyme-linked immunosorbent assay (ELISA). The most common clinical symptoms reported by laboratory-positive leptospirosis patients were fever (92%), headache (88%), and myalgia (83%). Three clinical symptoms were significantly less common among persons laboratory positive for leptospirosis when compared with the 122 patients who had been diagnosed with dengue fever during the outbreak: rash (p < 0.0001), chills (p = 0.05), and petechiae (p = 0.0005). Laboratory-positive leptospirosis infections were identified in persons exposed on each of the 5 most populous islands and illness onsets spanned a 10-month period, reflecting an endemic pattern of disease. If added to the figures obtained via routine passive surveillance, the number of leptospirosis infections identified through this study would more than double the annual incidence rate for Hawaii during 2001. These findings indicate that many leptospiral infections in Hawaii go undiagnosed. Physicians should maintain a high index of suspicion for leptospirosis when assessing patients presenting with acute febrile illness among residents and visitors to Hawaii.

On October 31, 2004, a stream overflowed, flooding the University of Hawaii (UH) campus. On November 19, 2004, a possible flood-related leptospirosis case (Patient 1) was reported to the Hawaii State Department of Health (HDOH). Surveillance for febrile illness was established through an Internet questionnaire. Active case finding was conducted among groups involved in the flood clean-up. Free leptospirosis testing was offered by HDOH. Patient 1's illness was confirmed as leptospirosis by microscopic agglutination testing. A total of 271 persons responded to the Internet survey, of whom 90 (33%) reported a febrile illness within 30 days of contact with flood water. Forty-eight respondents (18%) were tested for leptospirosis. One additional acute leptospirosis case was identified. Patient 2 was epidemiologically linked to Patient 1. Health care providers should maintain a high level of suspicion for leptospirosis after flooding events, and local public health officials should promote leptospirosis awareness among flood-affected populations.

The purpose of this study was to assess the objective bioterrorism-related knowledge base and the perceived response readiness of veterinarians in Hawaii to a bioterrorism event, and also to identify variables associated with knowledge-based test performance. An anonymous survey instrument was mailed to all licensed veterinarians residing in Hawaii (N = 229) up to three times during June and July 2004, using numeric identifiers to track non-respondents. The response rate for deliverable surveys was 59% (125 of 212). Only 12% (15 of 123) of respondents reported having had prior training on bioterrorism. Forty-four percent (55 of 125) reported being able to identify a bioterrorism event in animal populations; however, only 17% (21 of 125) felt able to recognize a bioterrorism event in human populations. Only 16% (20 of 123) felt they were able to respond effectively to a bioterrorist attack. Over 90% (106 of 116) expressed their willingness to provide assistance to the state in its response to a bioterrorist event. Veterinarians scored a mean of 70% correct (5.6 out of 8 questions) on the objective knowledge-based questions. Additional bioterrorism preparedness training should be made available, both in the form of continuing educational offerings for practicing veterinarians and as a component of the curriculum in veterinary schools.

Objective: To characterize the association of demographic factors with the relative hazards (RH) of developing AIDS or death among HIV-infected individuals of Asian/Pacific Islander (API) ethnicity and Whites., Design: Cohort study, Setting: Hawaii State Health Department database of HIV-infected individuals, Patients or Participants: Hawaii Sero-Positivity and Medical Management (HSPAMM) program participants from January 1989 to November 2002, Interventions: None, Main Outcome Measures: Differences in the time to develop AIDS or death among HIV-infected individuals who reported being on highly active antiretroviral treatment (HAART) were examined by ethnicity, income, and CD4+ cell counts at HAART initiation by using Kaplan-Meier survival analysis and Cox proportional hazard analyses., Results: The study was based on 516 HIV-infected individuals, who were primarily White (61.0%) and API (21.7%). Whites had a significantly higher CD4+ cell count (P<.01) and income (P<.01) than APIs at enrollment into HSPAMM. Lower income levels and CD4+ cell counts at HAART initiation were strongly associated with an increased RH of developing AIDS or dying. Despite having significantly lower incomes and CD4+ cell counts at enrollment, individuals of API ethnicity do not have an increased RH of developing the outcomes compared to Whites., Conclusion: Lower income and CD4+ cell counts at HAART initiation significantly increased the RH of developing AIDS or dying among HIV-infected individuals. Asian/Pacific Islander (API) ethnicity was not a predictor of developing AIDS or dying.

Introduction: Physicians and nurses are integral components of the public health bioterrorism surveillance system. However, most published bioterrorism preparedness surveys focus on gathering information related to self-assessed knowledge or perceived needs and abilities., Objective: A survey of physicians and nurses in Hawaii was conducted to assess objective knowledge regarding bioterrorism agents and diseases and perceived response readiness for a bioterrorism event., Methods: During June and July 2004, an anonymous survey was mailed up to three times to a random sample of all licensed physicians and nurses residing in Hawaii., Results: The response rate was 45% (115 of 255) for physicians and 53% (146 of 278) for nurses. Previous bioterrorism preparedness training associated significantly with knowledge-based test performance in both groups. Only 20% of physicians or nurses had had previous training in bioterrorism preparedness, and < 15% felt able to respond effectively to a bioterrorism event. But, > 70% expressed willingness to assist the state in the event of a bioterrorist attack., Conclusions: Additional bioterrorism preparedness training should be made available through continuing education and also should become a component of both medical and nursing school curricula. It is important to provide the knowledge necessary for physicians and nurses to improve their ability to perform in the event of a bioterrorist attack.

Background: The authors conducted a survey of dentists in Hawaii to assess their knowledge of, perceived readiness for and willingness to respond to bioterrorist (BT) events., Methods: Using a cross-sectional study design to access a random sample (n = 240) of all licensed dentists residing in the state of Hawaii (N = 1,016), the authors mailed study participants an anonymous survey up to three times during June and July 2004. Knowledge-based questions were taken from accredited Internet-based free continuing medical education offerings., Results: Of 234 deliverable surveys, 133 were returned (response rate of 56.8 percent). Only 2.3 percent of respondents reported having received prior BT preparedness training. A total of 14.5 percent felt able to identify and recognize a BT event, and 9.2 percent indicated they were able to respond effectively to a BT attack. A total of 73.8 percent expressed willingness to provide assistance to the state in the event of a BT attack. Dentists scored a mean of 62 percent correct (5.6 of nine questions) on the objective knowledge-based questions., Conclusions: A low prevalence of prior training coupled with a high degree of willingness to provide assistance indicates the need for additional BT preparedness training. This should be provided as continuing education offerings to practicing dentists and incorporated into the dental school curriculum., Clinical Implications: Dentists have the basic knowledge and experience to perform a number of key roles in a BT event; however, additional training must be provided to develop BT preparedness competencies.

Background: Remnant-like particles have been proposed as a new risk factor for coronary heart disease (CHD). This is the first long-term prospective investigation of the relationship between remnant-like particles and a cardiovascular disease outcome in healthy men., Methods and Results: A cohort of 1156 Japanese-American men aged 60 to 82 from the Honolulu Heart Program was followed for 17 years. During that period 164 incident cases of CHD were identified. In multivariate Cox regression analyses, baseline remnant-like particle cholesterol (RLP-C) and triglyceride (RLP-TG) levels were significantly related to CHD incidence independently of nonlipid cardiovascular risk factors and of total cholesterol or high-density and low-density lipoprotein cholesterol levels. Total triglyceride levels were an independent predictor of CHD incidence. However, in models including RLP and triglyceride level simultaneously, neither variable was significant when adjusted for the other. This finding can be attributed to the strong correlation between RLP-C and RLP-TG levels and total triglycerides. When individuals with normal triglyceride levels (n=894) were separated from those with elevated triglycerides (n=260), the association between RLPs and CHD relative risk was only significant for the group with elevated triglyceride levels., Conclusions: RLP levels predicted CHD incidence independently of nonlipid risk factors and of total cholesterol or high-density and low-density lipoprotein cholesterol levels. However, RLP levels did not provide additional information about CHD incidence over and above total triglyceride levels. Therefore, this study does not support the need for testing of remnants in men if measures of fasting triglycerides are available.

Limited studies have shown high rates of gonorrheal and chlamydial infections among incarcerated adolescents, however, this population has not been routinely targeted for sexually transmitted disease (STD) screening. This study was done to ascertain the feasibility of screening females for STDs at a juvenile detention facility in Honolulu, Hawaii, and to determine the prevalence of chlamydial and gonorrheal infections in this population. Between January 2000 and December 2001, pelvic examination-based STD screening was offered to all female detainees, on selected dates. Specimens from multiple anatomical sites were cultured for Neisseria gonorrhoeae. Endocervical swabs were tested for Chlamydia trachomatis using a DNA probe (GenProbe). One-hundred one of 204 (50%) eligible females were screened. Fourteen of 101 (13.9%) females were screen positive for chlamydial infection, while six of 101 (5.9%) were culture positive for infection with N. gonorrhoeae. Three females were co-infected with both organisms. The high STD rates justify the institution of a routine screening program for this high risk and previously underserved group.

Objective: National and state public health officials generally present sexually transmitted disease (STD) surveillance information in terms of overall cases and population-based rates. Because many adolescents (especially in the younger ages) are not sexually active, the use of population-based denominators leads to the calculation of low age-specific STD rates. This study compared morbidity rates with screening test positivity for gonorrhea and chlamydia to better define age-related STD risk among females in Hawaii., Methods: All female gonorrhea and chlamydia cases reported to the Hawaii State Department of Health (HDOH) during 2001 were grouped by age. Population estimates were used to calculate age-specific morbidity rates. Age-specific screening test positivity was calculated by dividing the number of positive tests identified through the HDOH STD screening programs by the number of screening tests performed in each age category (x100)., Results: Although morbidity rates for both chlamydia and gonorrhea were low among 10-14 year olds, this group had the highest screening test positivity. Screening test positivity decreased incrementally with increasing age., Conclusions: Screening test positivity may provide a more accurate estimate of STD risk for sexually active adolescents than population-based rates. Physicians should obtain sexual histories from their adolescent patients and provide STD prevention counseling and screening to those found to be sexually active. In addition, expanded STD screening and treatment services should be made available and accessible to young, sexually active adolescents because they appear to be at greatest risk.

Reliance on self-reported use of tobacco and intake of ethanol during pregnancy is associated with a high probability of error. Use of biological markers, or biomarkers, potentially offers a more valid method to assess exposure. Although cotinine is an established biomarker for tobacco use, there is no established biomarker for in utero ethanol exposure. Recent reports suggest that fatty acid ethyl esters (FAEE) could serve this purpose. To assess agreement between maternal self-reported tobacco use and ethanol intake during pregnancy and detection of metabolites associated with tobacco use (cotinine) and ethanol intake (FAEE), the authors studied maternal histories and meconium samples obtained in November-December 1999 from 436 consecutive mother-infant pairs at a large urban regional perinatal center in Honolulu, Hawaii. Cohen's kappa coefficient and 95% confidence intervals were calculated. Moderate agreement was found between reported tobacco use during the third trimester and detected cotinine level (kappa = 0.53, 95% confidence interval: 0.39, 0.68); however, there was no agreement between reported ethanol intake during the third trimester and detected FAEE (kappa = -0.02, 95% confidence interval: -0.04, 0.00). No mother reporting ethanol intake during the third trimester had detectable FAEE. Findings support the need for additional refinement and validation of the use of FAEE as a biomarker for maternal ethanol intake.

Purpose: For surveillance purposes, the Centers for Disease Control and Prevention and Council of State and Territorial Epidemiologists (CDC/CSTE) have defined two case classifications for leptospirosis: "confirmed" and "probable." The objective of this study was to provide data to refine the current surveillance case classifications., Methods: All reported leptospirosis infections from exposures within the State of Hawaii, 1974 to 1998 meeting CDC/CSTE "confirmed" and "probable" case classifications were compared on a number of clinical and epidemiologic parameters., Results: Confirmed cases (n = 276) had more severe clinical manifestations than probable cases (n = 180); however, probable cases with higher peak microscopic agglutination test (MAT) titers (> or =1:800) were clinically and epidemiologically comparable to confirmed cases. In addition, 77 cases demonstrating fourfold or greater MAT titer increases in paired serum collected less than two weeks apart (currently excluded from the "confirmed" case classification) were also comparable to confirmed cases., Conclusions: Our findings support amending the current CDC/CSTE surveillance confirmed case classification to include demonstration of a fourfold or greater MAT titer increase in paired serum, irrespective of the interval between specimen collection. Consideration should also be given to including single MAT titer > or =1:800 as a criterion for "confirmation." These changes would both simplify and expedite the surveillance confirmation of leptospirosis.